First lines of the practice of physic (Volume 1)

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UNITED STATES OF AMERICA

WASHINGTON, D. C.

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FIRST LINES ,

PRACTICE OF PHYSIC.

BY

WILLIAM OULLEN, M. D.

V

LATE PROFESSOR OF THE PRACTICE OF PHYSIC, IN THE UNIVERSITY OF
EDINBURGH, &c. &c.

WITH

NOTES AND OBSERVATIONS,

PRACTICAL AND EXPLANATORY,

V PRELIMINARY DISCOURSE,

IN DEFENCE OF CLASSICAL MEDICINE,

AND

AN APPENDIX,
By CHARLES CALDWELL, M. D.

PROFESSOR OF THE INSTITUTES OF MEDICINE IN TRANSYLVANIA UNIVERSITY,

SECOND EDITION, REVISED AND ENLARGED.
IN TWO VOLUMES,

VOL. I.

PHILADELPHIA:

PUBLISHED BY EDWARD PARKER,
No. 178 MARKET-STREET.

William Urovm, Printer.
1822.

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District of Pennsylvania, to wit:
*»*»**. BE IT REMEMBERED, That on the twenty-fourth day of Au-
J seal.; gust, in the forty-seventh year of the Independence of the United
••••••• states of America, A D. 1822, Edward Parker, of the said dis-
trict, hath deposited in this office the title of a book, the right whereof he
claims as Proprietor, in the words following, to wit:

"First Lines of the Practice of Physic. By William Cullen, M. D. Late
Professor of the Practice of Physic, in the University of Edinburgh,
&c. See. With Notes and Observations, Practical and Explanatory, a
Preliminary Discourse, in Defence of Classical Medicine, and an Ap-
pendix, by Charles Caldwell, M. D. Professor of the Institutes of Medi-
cine in Transylvania University. Second edition, revised and enlarged.
In Two Volumes. Vol. I."

In conformity to the act of the Congress of the United States, intituled,
" An act for the encouragement of learning, by securing the copies of maps,
charts, and books, to the authors and proprietors of such copies, during the
times therein mentioned." And also to the act, entitled, " An act supple-
mentary to an act, entitled, ' An act for the encouragement of learning, by
securing the copies of maps, charts, and books, to the authors and pro-
prietors of such copies during the times therein mentioned,' and extending
the benefits thereof to the arts of designing, engraving, and etching histori-
cal and other prints." *'

D. CALDWELL,

Clerk of the District of Pennsylvania

ADVERTISEMENT

BY THE EDITOR.

The first volume of the present edition is
not very greatly enlarged by original matter,
but tlie amount of notes we have added to the
second is considerable. Being partly disquisi-
tive and partly practical, we are not without
the hope, that, to most readers, these will be
found interesting and useful. On the score of
principle, we have stated nothing Avhich we do
not consider susceptible of defence, nor any
thing in relation to practice, which is not sanc-
tioned by ample experience.

But, perhaps, the most valuable additions we
have made will be found in the Appendix, which
is ample, and the greater part of which is ex-
tracted from authors of reputation.

It will be discovered by the reader, that se-
veral opinions advanced in these extracts, are at
variance with those which we ourselves have
hitherto maintained on the same subjects. It is
not to be hence inferred that we have abandoned
our ground. Far otherwise. Our views continue
the same as formerly. But being friendly to
liberal discussion, and having no wish to pro-

iv ADVERTISEMENT.

pagate opinions that are not supported by solid
argument, and which cannot bear the shock of
investigation, we felt ourselves called on by a
spirit of candour, to admit freely into this work,
which will be read chiefly by the young and
the inquiring, the sentiments of able and dis-
tinguished writers, however different they may
be from our own.

Our object being exclusively the inculcation
of truth, we would rejoice in the attainment of
so important an end, even by employing the
means furnished by others to correct or eradi-
cate our own errors.

Philadelphia, >
June 15th, 1822-5

CONTENTS

OF

THE FIRST VOLUME.

PAGE

DEDICATION, ix

Preface by the Editor, ------- x i

Preface by the Author, 1

Preliminary Discourse, by the Editor, 27

Tabular view of Cullen's Synopsis, - - - - 71
Introduction, - - --'--',-■ .83

PART I.

Of Pyrexia, or Febrile Diseases, .... 87

BOOK I.

Of Fevers, - - - - - - 87

Chap. I. Of the Phenomena of Fevers, - - 87

II. Of the Proximate Cause of Fever, - - 99

III. Of the Difference of Fevers, and its causes, 122

IV. Of the Remote Causes of Fevers, - - 131
V. Of the Prognosis of Fevers, - - 143

VI. Of the Method of Cure in Fevers, - - 154

Sect. I. Of the Cure in Continued Fevers, - 154

II. Of the Cure of Intermittent Fevers, 194

BOOK II.

Of Inflammations, or Phlegmasia, J- - - - 20G

Chap. I. Of Inflammation in genera* ... 200

Sect. I. Of the Phenomena of Inflammation, - - 200

II. Of the Proximate Cause of Inflammation, - 204

III. Of the Terminations of Inflammation, - 212

IV. Of the Remote Causes of Inflammation, - 218

V. Of the Cure of Inflammation, ... 220
Chap. II. Of Inflammation, more strictly Cutaneous, - 224

III. Of Ophthalmia, or Inflammation of the Eye, 227

IV. Of Phrensy, or Phrenitis, 232

V. Of the Quinsy, or Cynanche, ... 235

Sect. I. Of the Cynanche Tonsillaris, ... 236

II. Of the Cynanche Maligna, - - - 238

vi CONTENTS.

PAGE

Sect. III. Of the Cynanche Trachealis, ' - - -243

IV. Of the Cynanche Pharyngaea,

V. Of the Cynanche Parotidaea, - - - 249
Chap. VI. Of Pneumonic Inflammation, - - - '- 250

VII. Of Peripneumonia Notha, or Bastard Peripneu-

- 270

mony, - - *iv

VIII. Of the Gastritis, or Inflammation of the Stomach, 276
IX. Of the Enteritis, or Inflammation of the Intes-
tines, ..-----• 283
X. Of the Hepatitis, or Inflammation of the Liver, 285
XI. Of the Nephritis, or Inflammation of the Kid-
neys, - 291

XII. Of the Rheumatism, 295

XIII. Of the Toothach, or Odontalgia, - - 312

XIV. Of the Gout, 319

BOOK III.

Of Exanthemata, or Eruptive Fevers, ... 355

Chap. I. Of the Small-Pox, - 356

II. Of the Chicken-Pox, 383

III. Of the Measles, 384

IV. Of the Scarlet Fever, - - - - 391

V. Of the Plague, 397

Sect. I. Of the Phenomena of the Plague, - - 397

II Of the Prevention of the Plague, - - 401

III. Of the Cure of the Plague, - - - 405

Chap. VI. Of Erysipelas, or St. Anthony's Fire, - - 408

VII. Of the Miliary Fever, .... 413

VIII. Of the remaining Exanthemata :— Urticaria,

Pemphigus, and Aphtha, ... 422

BOOK IV.

Of Hjemorrhagies, ----.__ 426

Chap. I. Of Haemorrhagy in general, ... 426

Sect. I. Of the Phenomena of Haemorrhagy, - . 428

II. Of the Proximate Cause of Haemorrhagy, - 430

III. Of the remote Causes of Haemorrhagy, - 445

IV. Of the Cure of Haemorrhagy, - *" - - 447-
Chap. II. Of the Epistaxis, or Haemorrhagy of the Nose, 457

III. Of the Haemoptysis, or Haemorrhagy from the

Lungs, - - - - - . . 464

Sect. I. Of the Phenomena and Causes of Haemoptysis, 464
II. Of the Cure of Haemoptysis, - - . 470
Chap. IV. Of the Phthisis Pulmonalis, or Consumption of

the lungs, ...... 472

Sect. I. Of the Phenomena and Causes of the Phthisis

Pulmonalis, ----.. 472

II. Of the Cure of Phthisis, - 493

CONTENTS. v ii

PAGE

Chap. V. Of the Haemorrhois, or of the Haemovrhoidal

Swelling and Flux, 505

Sect. I. Of the Phenomena and Causes of the Haemor-
rhois, 505

II. Of the Cure of Hemorrhoidal Affections, - 513

APPENDIX.

Intermittent Fevers, „j

Remittent Fever, ----.__ x

Synochus, or Simple Continued Fever, - xv

Typhus Mitior, or Nervous Fever, - xxv

Typhus Gravior, or Malignant Putrid Fever, - - xxxix

Phlegmon, lj v

Erysipelas, Ixvii

Phrenitis, or Inflammation of the Brain and its Mem- *

branes, Ixviii *S

Ophthalmia, or Inflammation of the Eye, - - Ixviii
Cynanche Trachealis, or Croup, - - - lxxxii

Hepatitis, or Inflammation of the Liver, - - - xc

TO

NATHANIEL CHAPMAN, M. D.

PROFESSOR OF THE INSTITUTES AND PRACTICE OF ME-
DICINE, AND OF CLINICAL PRACTICE, IN THE
UNIVERSITY OF PENNSYLVANIA.

DEAR SIR,

IN addition to the gratification which the act affords
me, the highest I could experience on such an occa-
sion, there is a peculiar propriety in my prefixing your
name to the following pages.

For whatever benefit the physicians and students of
medicine of the United States may derive from the part
I have performed in preparing this work for the press,
it is fit they should know, that they will be as much in-
debted to you, as to myself. Although the labour has
been mine, that labour would not have been under-
taken, but for your advice and proffered patronage.

Placed, moreover, at the bead of that department of
medicine, to which this work especially belongs, you
not only possess the highest qualifications to judge of
the value of the additions I have made; but, publicly to
express your opinion respecting them, will constitute a
part of your official duty. Your approbation, already
so flatteringly signified, by adopting the present edition,

vol. i. b

X DEDICATION.

as the text-book to your lectures, will be its surest
passport to public favour.

But, in thus addressing you, I am actuated by other,
and, to myself, more highly interesting motives.

Pleased at your advancement in prosperity and re-
putation, and cherishing a lively sense of the tru>h and
steadiness of your friendship towards myself, I em-
brace, with eagerness, this opportunity of publicly ex-
pressing to you my joy at the one, and the high estima-
tion in which I hold the other. Nor should 1 either
be just to my own feelings, or stand acquitted of my
duty to you, were I to neglect the occasion which now
presents itself, of declaring my unqualified admiration
of your talents and skill, as a teacher and a practi-
tioner, and my exalted esteem for your virtues as a
man.

While delicacy towards your feelings prohibits me
from saying more, a sentiment of justice to your merit
forbids me to say less. Whether I may have found
the proper medium or not, of this I am confident, that
no one, acquainted with you, will accuse me of dealing
in exaggerated praise.

That your life may be long, illustrious, and happy,
and your example an object of honourable emulation
to the physicians of America, is the sincere wish of,
Dear Sir,

Your obliged Friend, and

Obedient Servant,

CHARLES CALDWELL.

Philadelphia, November 1, 1816.

PREFACE BY THE EDITOR

THE elaborate preface, by Dr. Cullen himself, being
sufficiently explanatory of the text of his " First Lines,"
nothing further is incumbent on us, than to assign a
reason for the Discourse we have prefixed, and the
Notes we have added. In the performance of this duty,
it shall be our aim, to observe as much conciseness, as
may be consistent with perspicuity.

To those, who, for the last twenty years, have been
conversant with the history of medicine in the United
States, it is perfectly known, that a bold and persever-
ing attempt was made, by the late Dr. Rush, to over-
throw entirely Methodical Nosology, and erect, on its
ruins, his favourite hypothesis of the Unity of Disease.
Nor was he altogether unsuccessful, in the pursuit of
his enterprise. By a combination of popular and im-
posing qualities, superadded to an ascendency, derived
from his station, as a public teacher, he implanted in
the minds of no inconsiderable portion of the physicians
of America, a disbelief in the truth and value of classi-
cal medicine.

To endeavour to counteract this evil, which, from
the simplicity it appeared to have introduced into me-

Xii PREFACE BY THE EDITOR.

dical science, and the facility it was supposed to give
in acquiring the knowledge of it, had become exceed-
ingly seductive of indolent minds; to recall the preva-
lence of correct principles, touching the subdivisions
and classification of disease, and to restore to our pro-
fession the advantages of system, constitute the object
of our preliminary discourse.

How far we may have succeeded in our aim, it does
not belong to us to determine. On this, as on all other
points, the intelligent reader is honestly invited to judge
for himself. We will be permitted, however, to ob-
serve, that, in our discussion of the subject, we have
attempted nothing, on the influence of precedent, or by
the weight of authority. Our sole reliance is on the
ground of argument and legitimate analysis. Nor do
we mean to arrogate any superiority to ourselves, but to
our cause, in saying, that, on that ground, we will en-
counter, with a confidence of success, any opposition
that can be arrayed against us.

In our very limited corrections of his nosological ar-
rangement, we have endeavoured to tread lightly on the
ashes of Dr. Cullen. His system abounds in error.
We have presented a tabular view of it, for two
reasons. It is, in the main, less exceptionable, than
any other, now extant: and it is the system pursued in
his First Lines of Practice. We have noticed only a
few of its most prominent faults, passing the minor
ones without remark.

How long it may be, before a more correct scheme
of nosology shall be prepared, we cannot predict. The

PREFACE BY THE EDITOR. xiii

object is practicable, and will, certainly, be achieved.
Nor are we without a lively hope, that the honour of the
enterprise will belong to our own country: for, how-
ever strangely the declaration may sound, in some
places abroad, or offensively, in others, we are con-
vinced, from an examination of evidence, to which
credit seems due, that there exists, in the medical
mind of the United States, a degree of boldness,
originality, and vigour, which have at present no pa-
rallel, in the minds of the physicians of the old
world. If, then, to the intellectual endowments, which
a beneficent and bounteous Creator has conferred on
them, and the unlimited field of observation he has
given them to enjoy, the physicians of America add,
what cultivation and industry are calculated to bestow,
the result cannot fail to be eminently honourable to
themselves and their country; and no less advantageous
to the human race.

In our notes to the present edition of Cullen's First
Lines, our object has been to elucidate obscurities,
correct errors, and supply deficiencies: to bring the
work, in point of principle, from the period at which
it was written, through the progressive improve-
ment in science, up to the present time; and, by mould-
ing it into a system of American practice, to render
it better suited to the instruction of students of me-
dicine, and inexperienced practitioners, in the United
States.

That there existed ample grounds, and cogent rea-
sons, for such an undertaking, cannot be denied.

x iv PREFACE BY THE EDITOR.

" The First Lines of Practice," as they came from
the pen of their illustrious author, constitute a work
of inequalities and contrasts; marked by excellencies, of
a superior order, intermingled with imperfections both
numerous and great Like most other productions of
superior intellect, their good and bad qualities are on
the same scale.

The histories and descriptions of diseases, with
which this work presents us, are confessedly unrivalled.
Nor ought less, perhaps, to be said of many of its ex-
positions of the indications of cure: they, also, are
clear, pertinent, and accurately drawn, beyond what
is to be found in any other publication with which we
are acquainted.

In addition to this, the entire work, notwithstanding
its defects, is comprehensive, in its outline, and much
more classical and systematic, in its plan, than any other
of the kind that has hitherto appeared. With Thomas's
Practice of Physic, which is nothing but a compilation,
it would be injustice to compare it. Much of the most
valuable matter contained in that work will be found
in the Appendix to the present edition.

For these reasons, the work of Cullen has been long
used, in Great Britain and A merica, as a tex-tbook for
teachers; and has been uniformly placed in the hands
of students of medicine, as their best scientific and
practical guide.

But, in this country, its faults have been considered
for several years past, as counterbalancing, m some
measure, its numerous excellencies.

PREFACE BY THE EDITOR. • xv

On topics of theory, whether they relate to physi-
ology, pathology, or therapeutics, many of its discus-
sions are exceedingly erroneous; and its defects, with
regard to remedies, and modes of cure, are by no means
inconsiderable. It retains not a few of the exploded
notions of the humoral pathology; and, although suffi-
ciently vigorous, perhaps, in the climate of Great Bri-
tain, where Nature seems to operate on a more limited
scale, the treatment it recommends is, oftentimes, fee-
ble and wholly inefficient, when opposed to the fierce
character and rapid march of the more formidable dis-
eases of the United States.

Nor does the imbecility of the professor's practice,
constitute its only, or even its greatest, imperfection.
It is marked, in many cases, with unqualified error; a
fault, that must necessarily have proved, in innumer-
able instances, signally mischievous, in its influence on
society.

From these causes, Cullen's "First Lines" without
notes, is a work, dangerous, in its effects, on the inex-
perienced cultivators of medical science. Hence, the
late declaration of a distinguished teacher, that he
" would as soon think of placing, in the hands of a stu-
dent of divinity, the writings of Thomas Paine, as of
recommending, to a student of physic, Dr. Cullen's
Practice, unaccompanied by the requisite corrections''

It is with a view to afford such "corrections," and
to supply deficiencies, that our notes are annexed to
the present edition.

Although, from their being principally the result of

xv i PREFACE BY THE EDITOR.

our own experience, we might be supposed to hold
the additions we have made in some estimation; yet,
were that our only source of reliance, we should feel
no small degree of diffidence, in submitting them to the
public. But we have ample encouragement from ano-
ther quarter.

After a careful perusal of what we have written, the
Professor of the Institutes and Practice of Medicine,
in the University of Pennsylvania, whose approbation
amounts to honourable applause, has, on account of the
Notes, and Preliminary Discourse, adopted our edition
of Cullen's " First Lines" as the text-book to his lec-
tures. This speaks a language, which needs no com-
mentary; and, which the physicians of America will
know how to respect

Unwilling, however, to repose exclusively on the
sanction of high authority, we think it due, as well to
ourselves as our readers, to remark, that, whatever im-
perfections or faults our additions may contain, are
not the result of either indolence or neglect. From
the moment we engaged in the preparation of them,
no exertions were wanting, on our part, to render them
useful to the student, and worthy of the approbation
of the experienced practitioner.

Superadded to our own personal resources, in mat-
ters of practice, we consulted the best writers, to which
we could have access; availed ourselves of information
from our medical correspondents: and held repeated
conferences with some of the most distinguished phy-
sicians of Philadelphia. From each of these sources, we

PREFACE BY THE EDITOR. xvii

derived advantage; but profited more abundantly by the
free and enlightened communications from the latter.

To have made known the names of the several gen-
tlemen, to whom we are indebted, for practical informa-
tion, would have afforded us pleasure: but their delicacy
forbade the indulgence of our feelings. We can only
beg them, therefore, to receive, each one for himself,
the homage of our thanks. We must not, however, con-
ceal the fact, that Dr. Chapman, with a frankness and
liberality peculiarly his own, threw open to us several of
his manuscript lectures, permitting us, not only to con-
sult them, but to extract from their contents whatever
we thought proper. Had our leisure and limits allowed
us to avail ourselves more extensively of this privilege,
we are sensible that our notes would have been, not a
little, augmented in utility and value.

There is one point, which may appear, to some, to
require an explanation, if not an apology.

Of the remedies recommended, we have not always
mentioned either the doses or the modes of exhibition.
The reason is, that the insertion of numerous formulas,
besides giving a page an unsightly appearance, would
have necessarily, increased the expenses of the work,
much more than it would have increased its value.

Every physician in the United States, ought to at-
tend lectures on the Materia Medica; and must possess
some work on that subject, as well as on Pharmacy. A
Dispensatory, at least, is as necessary on his shelf, as a
lancet is in his pocket. It is from these sources, that he

vol. j c

xviii PREFACE BY THE EDITOR.

must learn the doses of medicines, as well as their pre-
paration, and modes of exhibition.

In our own estimation, therefore, an omission to swell
and encumber our pages, with pharmaceutical details,
is no fault; nor can we entertain a doubt, that, on due
reflection, all those, whose approbation we regard, will
concur with us in opinion.

Philadelphia, November 1, 1816.

PREFACE.

JTO deliver a System of the Doctrines and Rules pro-
per for directing the Practice of Physic, is an undertak-
ing that appears to me to be attended with great diffi-
culty ; and after an experience of more than forty years
in that practice, as well as after much reading and
reflection, it was with great diffidence that I ever enter-
ed upon such a work. It was, however, what seemed to
be my duty as a Professor that induced me to m^ike the
attempt; and I was engaged in it by the same sentiments
that the illustrious Dr. Boerhaave has expressed in the
following passage of the preface to his Institutions :
" Simul enim docendo admotus eram sensu, propriorum
cogitatorum explicatione docentem plus proficere, quam
si opus ab alio conscriptum interpretari suscipit. Sua
quippe optime intelligit, sua cuique prae caeteris pla-
cent, unde clarior fere doctrina, atque animata plerum-
que sequitur oratio. Qui vero sensa alterius exponit,
infelicius saepenumero eadem assequitur; quumque suo
quisque sensu abundat, multa refutanda frequenter in-
venit, unde gravem frustra laborem aggravat, minusque
incitata dictione utitur." It is well known, that a
Text-book is not only extremely useful, but necessary
to Students who are to hear Lectures; and from the
same considerations that moved Dr. Boerhaave, I also
wished to have one for myself; while at the same time.

VOL. I. A

2 PREFACE.

from some peculiar circumstances in my situation, 1
had some additional inducements to undertake such a
work.

Before I was established as Professor of the Practice
of Physic in this University, I had been employed in
giving Clinical Lectures in the Royal Infirmary; and
upon that occasion had delivered, what, in my own
opinion, seemed most just with regard to both the na-
ture and the cure of the diseases of which I had occa-
sion to treat. But I soon found, that my doctrines
were taken notice of^ as new, and peculiar to myself;
and were accordingly severely criticised by those who,
having long before been trained up in the system of
Boerhaave, had continued to think that that system
neither required any change, nor admitted of any amend-
ment. I found, at the same time, that my doctrines were
frequently criticised by persons who either had not
been informed of them correctly, or who seemed not to
understand them fully; and therefore, as soon as I was
employed to teach a more complete system of the Prac-
tice of Physic, I judged it necessary to publish a Text-
book, not only for the benefit of my hearers, but that I
might also have an opportunity of obtaining the opinion
of the public more at large, and thereby be enabled
either to vindicate my doctrines, or be taught to correct
them. These were the motives for my attempting the
volumes I formerly published; and now, from many
years experience of their utility to my hearers, as well
as from the favourable reception they have met with
from the public, I am induced to give a new edition of
this Work, not only, as I hope, more correct in many
parts, but also more complete and comprehensive in its
general extent.

At the first publication of this work, it was intended
chiefly for the use of those gentlemen who attended my

PREFACE. 3

lectures ; although even then, for the reasons I have men-
tioned, it was rendered more full than text-books com-
monly are; and, in the repeated editions I have since
had occasion to give, I have been constantly endeavour-
ing to render it more full and comprehensive. In these
respects, I hope the present edition will appear to be
rendered more fit for general use, and better calulated
to afford satisfaction to all those who think they may
still receive any instruction from reading on this subject.

While I thus deliver my work in its now more im-
proved state, with the hopes that it may be of use to
others as well as to those who hear my Lectures, I must
at the same time observe, that it presents a system
which is in many respects new, and therefore I appre-
hend it to be not only proper, but necessary, that I
should explain here upon what grounds, and from what
considerations, this has been attempted.

In the first place, I apprehend that, in every branch
of science with respect to which new facts are daily ac-
quired, and these consequently giving occasion to new
reflections, which correct the principles formerly adopt-
ed, it is necessary, from time to time, to reform and
renew the whole system, with all the additions and
amendments which it has received and is then capable
of. That at present this is requisite, with regard to the
Science of Medicine, will, I believe, readily occur to
every person who at all thinks for himself, and is ac-
quainted with the Systems which have hitherto pre-
vailed. While, therefore, I attempt this, I think it may
be allowable, and upon this occasion even proper, that
I should offer some remarks on the principal Systems
of Medicine which have of late prevailed in Europe,
and that I should take notice of the present state of
Physic as it is influenced by these. Such remarks, I

4 PREFACE.

hope, may be of some use to those who attempt to im-
prove their knowledge by the reading of books.

Whether the practice of Physic should admit of rea-
soning, or be entirely rested upon experience, has long
been, and may still be, a matter of dispute. I shall not,
however, at present, enter upon the discussion of this ;
because I can venture to assert, that, at almost all times,
the practice has been, and still is, with every person,
founded more or less, upon certain principles establish-
ed by reasoning; and therefore, in attempting to offer
some view of the present state of Physic, I must give
an account of those systems of the principles of science
which have lately prevailed, or may be supposed still to
prevail in Europe.

When, after many ages of darkness, which had de-
stroyed almost the whole of ancient literature, learning
was again restored in the fifteenth century ; so from
causes which are well known, it was the system of Ga-
len alone that ihe Physicians of those days became ac-
quainted with ; and during the course of the sixteenth
century, the study of Physicians was almost solely em-
ployed in explaining and confirming that system. Early,
indeed, in the sixteenth century, the noted Paracelsus
had laid the foundation of a Chemical system which
was in direct opposition to that of Galen ; and, by the
efficacy of the medicines employed by Paracelsus and
his followers, their system came to be received by
many: but the systematic Physicians continued to be
chiefly Galenists, and kept possession of the Schools till
the middle of the seventeenth century. It is not how-
ever, necessary here to enter into any further detail re-
specting the fate of those two opposite sects ; for the only
circumstance concerning them, which I would at present
point out, is, that in the writings of both, the explana-
tions they severally attempted to give of the phenomena

PREFACE. 5

of health or sickness, turned entirely upon the state of
the fluids of the body.

Such was the state of the science of Physic till about
the middle of the seventeenth century, when the circu-
lation of the blood came to be generally known and
admitted ; and when this, together with the discovery of
the receptacle of the chyle, and of the thoracic duct,
finally exploded the Galenic system. About the same
period a considerable revolution had taken place in the
system of Natural Philosophy. In the course of the se-
venteenth century, Galileo had introduced mathematical
reasoning; and Lord Bacon having proposed the me-
thod of induction, had thereby excited a disposition to
observe facts, and to make experiments. These new
modes of philosophising, it might be supposed, would
soon have had some influence on the state of medicine ;
but the progress of this was slow. The knowledge of
the Circulation did indeed necessarily lead to the consi-
deration as well as to a clearer view of the Organic Sys-
tem in animal bodies; which again led to the applica-
tion of the mechanical philosophy towards explaining
the phenomena of the animal economy ; and it was ap-
plied accordingly, and continued, till very lately, to be
the fashionable mode of reasoning on the subject. Such
reasoning, indeed, must still in several respects continue
to be applied : but it would be easy to show, that it nei-
ther could, nor ever can be, applied to any great ex-
tent in explaining the animal economy; and we must
therefore look for other circumstances which had a
greater share in modelling the system of Physic.

With this view, it may be remarked, that till the pe-
riod just now mentioned, every Physician, whether
Galenist or Chemist, had been *o much accustomed to
consider the state and condition of the fiukis, both as
the cause of disease, and as the foundation for explain-

6 PREFACE.

ing the operation of medicines, that what we may term
an humoral pathology still continued to make a great
part of every system. In these circumstances, it was
soon perceived, that chemistry promised a much better
explanation than the Galenic or Aristotellian philoso-
phy had done; and, therefore, while the latter was en-
tirely laid aside, a chemical reasoning was every where
received. Lord Bacon, with his usual sagacity, had
early observed, that chemistry promised a great number
of facts, and he thereby gave it credit; whilst the Cor-
puscularian philosophy, restored by Gassendi, readily
united with the reasonings of the Chemists ; and the
Philosophy of Des Cartes readily united with both.
From all these circumstances, an Humoral, and chiefly
a Chemical Pathology, came to prevail very much till
the end of the last century; and has, indeed, continued
to have a great share in our systems down to the pre-
sent time.

It is proper now, however, to observe, that about the
beginning of the present century, when every part of
science came to be on a more improved and correct
footing, there appeared in the writings of Stahl, of
Hoffman, and of Boerhaave, three new^ and con-
siderably different, Systems of Physic; which have ever
since had a great share in directing the practice of it.
In order, therefore, to give a nearer view of the present
state of Physic, I shall offer some remarks upon these
different systems; endeavouring to point out the advan-
tages, as well as the disadvantages of each, and how far
they still prevail ; or, according to my judgment, deserve
to do so.

I shall begin with considering that of Dr. Stahl,
which I think appeared first, and for a long time after
was the prevailing system in Germany.

The chief and leading principle of this system is, that

PREFACE. 7

the rational soul of man governs the whole economy of
his body. At all times, Physicians have observed that
the animal economy has in itself a power or condition,
by which, in many instances, it resists the injuries
which threaten it; and by which it also, on many occa-
sions, corrects or removes the disorders induced, or
arising in it. This power, Physicians very anciently
attributed, under a vague idea, to an agent in the sys-
tem, which they called nature; and the language of a
vis conservatrix et medicatrix natures, has continued in
the schools of medicine from the most ancient times to
the present.

Dr. Stahl has explicitly founded his system on the
supposition that the power of nature, so much talked
of, is entirely in the rational soul. He supposes, that
upon many occasions, the soul acts independently of
the state of the body; and that, without any physical
necessity arising from that state, the soul, purely in
consequence of its intelligence perceiving the tendency
of noxious powers threatening, or of disorders any wise
arising in the system, immediately excites such motions
in the body as are suited to obviate the hurtful or per-
nicious consequences which might otherwise take place.
Many of my readers may think it was hardly necessary
for me to take notice of a system founded upon so fan-
ciful an hypothesis; but there is often so much seeming
appearance of intelligence and design in the operations
of the animal economy, that many eminent persons, as
Perrault in France, Nichols and Mead in England,
Porterfald and Simson in Scotland, and Gaubius in
Holland, have very much countenanced the same opi-
nion, and it is therefore certainly entitled to some regard.
It is not, however, necessary for me here to enter into
any refutation of it. Dr. Hoffman has done this fully,
in his Commentarius de differentia inter Hqffmanni doc-

8 PREFACE.

trinam medico-mechanicam et G. E. Stahlii medicQ-or-
ganicam; and both Boerhaave and Haller, though no
favourers of materialism, have mentioned a doctrine very
opposite to that of Stahl.

In my Physiology I have offered some arguments
against the same; and I shall only add now, that who-
ever considers what has been said by Dr. Nichols in his
Oratiode AmmaMedica, and by Dr. Gaubius in some
some parts of his Pathology, must perceive, that the
admitting of such a capricious government of the ani-
mal economy, as these authors in some instances sup-
pose, would at once lead us to reject all the physical
and mechanical reasoning we might employ concerning
the human body. Dr. Stahl himself seems to have been
aware of this; and therefore in his preface to Juncker's
Conspectus Therapeia Specialis, has acknowledged, that
his general principle was not at all necessary; which
is in effect saying that it is not compatible with any
system of principles that ought to govern our practice.
Upon this footing, I might have at once rejected the
Stahlian principle: but it is even dangerous to bring any
such principle into view; for, after all Dr. Stahl had
said in a passage just now referred to, I find, that, in the
whole of their practice, both he and his followers have
been very much governed by their general principle.
Trusting much to the constant attention and wisdom of
nature, they have proposed the Art of curing by expec-
tation; have therefore, for the most part, proposed only
very inert and frivolous remedies; have zealously op-
posed the use of some of the most efficacious, such as
opium and the Peruvian bark; and are extremely re-
served in the use of general remedies, such as bleeding,
vomiting, &c.

Although these remarks, upon a system which may
now be considered as exploded or neglected, may seem

PREFACE. 9

superfluous; I have been willing to give these strictures
on the Stahlian system, that I might carry my remarks
a little farther, and take this opportunity of observing,
that, in whatever manner we may explain what have
been called the operations of nature, it appears to me,
that the general doctrine of Nature curing diseases, the
so much vaunted Hippocratic method of curing, has
often had a baneful influence on the practice of physic;
as either leading physicians into, or continuing them in,
a weak and feeble practice; and at the same time su-
perseding or discouraging all the attempts of art. Dr.
Huxham has properly observed that even in the hands
of Sydenham it had this effect. Although it may some-
times avoid the mischiefs of bold and rash practitioners,
yet it certainly produces that caution and timidity which
have ever opposed the introduction of new and effica-
cious remedies. The opposition to chemical medicines
in the sixteenth and seventeenth centuries, and the
noted condemnation of Antimony by the Medical Fa-
culty of Paris, are to be attributed chiefly to those pre-
judices, which the physicians of France did not entirely
get the better of for near an hundred years after. We
may take notice of the reserve it produced in Boer-
haave, with respect to the use of the Peruvian bark.
We have had lately published, under the title Consti-
tutiones Epidemical, notes of the particular practice of
the late Baron Van Swieten : upon which the editor
very properly observes, That the use of the bark, in in-
termitting fevers, appears very rarely in that practice;
and we know very well where Van Swieten learned that
reserve.

I might go farther, and show how much the attention
to the jlutocrateia, allowed of, in one shape or other,
by every sect, has corrupted the practice among all
physicians, from Hippocrates to Stahl. It must, how-

VOL. I. B

10 PREFACE.

ever, be sufficiently obvious, and I sboll conclude the
subject with observing, that although this vis medica-
trix natures, must unavoidably be received as a fact;
yet wherever it is admitted, it throws an obscurity upon
our system; and it is only where the impotence of our
art is very manifest and considerable, that we ought to
admit of it in practice.

To finish our remarks upon the Stahlian system, I
shall shortly observe, that it did not depend entirely
upon the Avtocraleia, but also supposed a state of the
body and diseases, that admitted of remedies, which,
under the power and direction of the soul, acted upon
the organization and matter of the body, so as to cure
its diseases. Upon this footing, the Stahlian pathology
turned entirely upon Plethora and Cacochymy. It was
with respect to the former that they especially applied
their doctrine of the Jiutocrateia in a very fantastical
manner; and, with respect to the latter, they have been
involved in a humoral pathology as much as the syste-
matic physicians who had gone before them, and with
a theory so incorrect as not to merit the smallest atten-
tion. After all, I ought not to dismiss the consideration
of the Stahlian system, without remarking, that as the
followers of this system were very intent upon observ-
ing the method of nature, so they were very attentive in
observing the phenomena of diseases, and have given
us in their writings many facts not to be found else-
where.

While the doctrines of Stahl were prevailing in the
university of Halle, Dr. Hoffman, a professor in the
same university, proposed a system that was very dif-
ferent. He received into his system a great deal of the
mechanical, Cartesian, and chemical doctrines of the
systems which had appeared before: but with respect to
these, it is of no consequence to observe in what man-

PREFACE. 11

ner he modified the doctrines of his predecessors, as his
improvements in these respects were no ways consider-
able, and no part of them now remain; and the real
value of his works, beyond what I am just now going
to mention, rests entirely on the many facts they con-
tain. The merit of Dr. Hoffman and of his works is,
that he made, or rather suggested, an addition to the
system, which highly deserves pur attention. Of this I
cannot give a clearer account than by giving it in the
author's own words. In his Medicina Rationalis Sys-
tematica, Tom. III. § 1. chap. iv. he has given his
Genealogia morborum ex turbato solidorum et Jluido-
rum mechanismo; and in the 47th and last paragraph
of this chapter he sums up his doctrine in the following
words: ' c Ex hisce auteni omnibus uberius hactenus
excussis, per quam dilucide apparere arbitror, quod so-
lus spasmus et simplex atoma, aequabilem, liberum, ac
proportionatum sanguinis omnisque generis fluidorum
motum, quibus excretionum successus et integritas
functionum animi et corporis proxime nititur, turbando
ac pervertendo, universam vitalem oeconomiam subru-
ant ac destruant; atque hinc universa pathologia longe
rectius atque facilius ex vitio motuum microcosmico-
rum in solidis, quam ex varus affectionibus vitio-
sorum humorum, deduci atque explicari possit, adeo-
que omnis generis aegritudines internae, ad pr^ter>a-
turale> generis nervosi affectiones sint referendae.
Etenim laesis quocunque modo, vel nervis per corpus
discurrentibus, vel membranosis quibusvis nervosis par-
ibus, illico motuum anomaliae, modo lev iores, modo gra-
viores subsequuntur. Deinde attenta observatio docet,
motus quosvis morbosos principaliter sedem Agere et
tyrannidem exercere in nervosis corporis partibus, cujus
generis proeter omnes canales, qui systaltico et diastal-
tico motu pollentes, contentos succos tradunt, univer-

12 PREFACE.

sum nimirum intestinorum et ventriculi ab oesopbago
ad anum canalem, totum systema vasorurn artenoso-
rum, ductuum biliariorum, salivalium, urinarioruni et
subcutaneorum, sunt quoque mcmbranae nerveo-mus-
culares cerebri et medullas spinalis, praesertim ha3c, qu;v
dura mater vocatur, organis sensoriis obductae, nee nen
tunicas illae ac ligamenta, qua; ossa cingunt artusque
firmant. Nam nullus dolor, nulla inflammatio, nulltts
spasmus, nulla motus et sensus impotenlia, nulla febrifi
humoris illius excretio, accidit, in qua non has partes
patiantur. Porro etiam omnes, quae morbos gignunt
causae, operationem suam potissiniam perficiunt in par-
tes motu et sensu prasditas, et canales ex his coagmen-
tatos, eorum motum, et cum hoc fluidorum cursum,
perventendo ; ita tamen, ut sicuti variae indolis sunt, sic
etiam varie in nerveas partes agant, iisdemque noxam
affiricent. Demum omnia quoque eximiae virtutis medi-
camenta, non tarn in partes fluidas, earum crasin ac in-
temperiem corrigendo, quam potius in solidas et nervo-
sas, earundem motus alterando ac moderando, suam
edunt operationem: De quibus tamen omnibus, in vul-
gari usque eo recepta morborum doctrina, altum est si-
lent ium."

It is true, that Dr. Willis had laid a foundation for
this doctrine, in his Pathologia Cerebri et Nervorum;
and Baglivi had proposed a system of this kind in his
Specimen de fibra motrici et morbosa. But in these wri-
ters it was either not extensively applied to diseases, or
was still so involved in many physiological errors, that
they had attracted little attention ; and Dr. Hoffman was
the first who gave any tolerable simple and clear system
on the subject, or pointed out any extensive application
of it to the explanation of diseases.

There can be no sort of doubt that the phenomena of
the animal economy in health and in sickness, can only

PREFACE. 13

be explained by considering the state and affections of
the primary moving powers in it. It is to me surprising
that physicians were so long in perceiving this, and I
think we are particularly indebted to Dr. Hoifman for
putting us into the proper train of investigation; and it
every day appears that physicians perceive the neces-
sity of entering more and more into this inquiry. It was
this. I think, which engaged Dr. Kaaw Boerhaave to
publish his work entitled Impctumjacieiis; as well as
Dr. Gatibius to give the Pathology of the Solidum vi-
vum. Even the Baron Van Swieten has upon the
same view thought it necessary, in at least one particu-
lar, to make a very considerable change in the doctrine
of his master, as he has done in his Commentary upon
the 775th Aphorism. Dr. Haller has advanced this
part of science very much by his experiments on irrita-
bility and sensibility. In these and in many other in-
stances, particularly in the writings of Mr. Barthez of
Montpelier, of some progress in the study of the affec-
tions in the Nervous System, we must perceive how
much we are indebted to Dr. Hoffman for his so pro-
perly beginning it. The subject, however, is difficult:
the laws of the Nervous System, in the various circum-
stances of the animal economy, are by no means ascer-
tained; and from want of attention and observation with'
the view to a system on this subject, the business appears
to many as an inexplicable mystery. There is no won-
der therefore, that on such a difficult subject, Dr. Hoff-
man's system was imperfect and incorrect; and has had
less influence on the writings and practice of physicians
since his time, than might have been expected. He
himself has not applied his fundamental doctrine so ex-
tensively as he might have done; and he has every
where intermixed a Humoral Pathology, as incorrect
and hypothetical as any other. Though he differed

U PREFACE.

from his colleague Dr. Stahl in the fundamental doc-
trines of his system, it is but too evident that he was
very much infected with the Stahlian doctrines of Ple-
thora and Cacochymy, as may be observed throughout
the whole course of his work; and particularly in his
chapter Da morborum generations ex nimia sanguinis
qunnlitate el humorum impuritate.

But it is needless for me to dwell any longer upon the
system of Hoffman; and I am next to offer some re-
marks on the system of Dr. Boerhaave, the contempo-
rary of. both the other Systematics, and who, over all
Europe, and especially in this part of the world, gained
higher reputation than either of the others.

Dr. Boerhaave was a man of general erudition; and,
in applying to medicine, he had carefully studied the
auxiliary branches of Anatomy, Chemistry, and Botany,
so that he excelled in each. In forming a system of
Physic, he seems to have studied diligently all the se-
veral writings of both ancient and modern Physicians;
and, without prejudice in favour of any former systems,
he endeavoured to be a candid and genuine eclectic.
Possessed of an excellent systematic genius, he gave a
system superior to any that ever before appeared. As in
the great extent, and seemingly perfect consistency, of
system, he appeared to improve and refine upon every
thing that had before been offered; and as in his Lec-
tures he explained his doctrines with great clearness and
elegance, he soon acquired a very high reputation, and
his system was more generally received than any for-
mer had been since the time of Galen. Whoever will
consider the merits of Dr. Boerhaave, and compare his
system with that of former writers, must acknowledge
that he was very justly esteemed, and gave a system
which was at that time deservedly valued.

But, in the progress of an inquisitive and industrious

PREFACE. ]5

age, it was not to be expected that any system should
last so long as Boerhaave's has done. The elaborate
Commentary of Van Svvieten on Boerhaave's system of
practice, has been only finished a few years ago; and
though this Commentator has added many facts, and
made some corrections, he has not, except in the parti-
cular mentioned above, made any improvement in the
general system. It is even surprising that Boerhaave
himself, though he lived near forty years after he had
first formed his system, had hardly in all that time made
any corrections of it or additions to it; the following is
the most remarkable. In Aphorism 755, the words
forte et nervosi, tarn cerebri quam cerebelli cordi destinaii
inertia, did not appear in any edition before the fourth;
and what a difference of system this points at, every
physician must perceive.

When I first applied to the study of Physic, I learned
only the system of Boerhaave; and even when I came to
take a Professor's chair in this university, I found that
system here in its full force; and as I believe it still sub-
sists in credit elsewhere, and that no other system of
reputation had been offered to the world, I think it ne-
cessary for me to point out particularly the imperfec-
tions and deficiencies of the Boerhaavian system, in or-
der to show the propriety and necessity of attempting a
new one.

To execute this, however, so fully as I might, would
lead me into a detail that can hardly be admitted of here;
and I hope it is not necessary, as I think, that every in-
telligent person, who has acquired any tolerable know-
ledge of the present state of our science, must in many
instances perceive its imperfections. I shall therefore
touch only upon the great lines of this system; and from
the remarks I am to offer, trust that both the mistakes

lt> PREFACE.

and deficiencies which run through the whole of his
works will appear.

Dr. Boerhaave's treatise of the diseases of the simple
solid, has the appearance of b< ing very clear and consis-
tent, and was certainly considered by him as a funda-
mental doctrine; but, in my apprehension, it is neither
correct nor extensively applicable, not to mention the
us less, and perhaps erroneous, notion of the composi-
tion of earth and gluten; nor his mistake concerning the
structure of compound membranes; nor his inattention
to the state of the cellular texture; all of them circum-
stances which render his doctrine imperfect; I shall in-
sist only upon the whole being very little applicable to
the explaining the phenomena of health or sickness.
The laxity or rigidity of the simple solid, does, indeed,
take place at the different periods of life, and may per-
haps, upon other occasions, occur as the cause of dis-
ease; but I presume, that the state of the simple solid
is, upon few occasions, either changeable or actually
changed; and that in ninety-nine cases of an hundred,
the phenomena attributed to such a change, do truly
depend on the state of the solidum vivum; a circum-
stance which Dr. Boerhaave has hardly taken notice of
in any part of his works. How much this shows the
deficiency and imperfection of his system, I need not
explain. The learned work of Dr. Gaubius, above re-
ferred to, as well as many other treatises of late authors,
point out sufficiently the defects and imperfections of
Boerhaave on this subject.

After Dr. Boerhaave has considered the diseases of
the solids, he in the next place attempts to explain the
more simple diseases of the fluids; and there indeed he
delivers a more correct doctrine of acid and alkali than
had been given before: but, after all, he has done it very
imperfectly. We have, indeed, since his time, acquired

PREFACE. j7

more knowledge upon the subject of digestion ; and so
much as to know, -that a great deal more is yet neces-
sary to enable us to understand in what manner the ani-
mal fluids are formed from the aliments taken in. And
although Dr. Boerhaave has fallen into no considerable
error with respect to a morbid acidity in the stomadh,
he could not possibly be complete upon that subject;
and his notion of the effects of acidity in the mass of
blood, seems to have been entirely mistaken, and is, in-
deed, not consistent with what he himself has delivered
elsewhere.

His doctrine of alkali is somewhat better founded, but
is probably carried too far; and the state of alkales-
cency and putrefaction, as well as all the other changes
which can take place in the condition of animal fluids,
are particulars yet involved in great obscurity, and are
therefore still subjects of dispute.

There is another particular, in which Boerhaave's
doctrine concerning the fluids appears to me imperfect
and unsatisfactory; and that is, in his doctrine de Glu-
tinnso spontanea. The causes which he has assigned
for it are by no means probable, and the actual existence
of it is seldom to be proved. Some of the proofs ad-
duced for the existence of a phle*jma calidum, are mani-
festly founded upon a mistake with respect to what has
been called the inflammatory crust, (See Van Swieten's
Commentary, page 9G ); and the many examples given
by Boerhaave of a glutinosum appearing in the human
body, (Aph. 75.) are all of them nothing more than in-
stances of collections or concretions found out of the
course of the circulation.

If, then, we consider the imperfections of Dr. Boer-
haave's doctrine with respect to the state and various
condition of the animal fluids; and if at the same time
we r fleet how frequently he and his followers have em-
vol. i. e

18 PREFACE.

ployed the supposition of an acrimony or lentor of the^
fluids, as causes of disease, and for directing the prac-'
tice; we must, as I apprehend, be satisfied, that his sys-
tem is not only deficient and incomplete, but fallacious
and apt to mislead. Although it cannot be denied, that
the fluids of the human body suffer various morbid
changes; and that upon these diseases may primarily
depend; yet I must beg leave to maintain, that the na-
ture of these changes is seldom understood, and more,
seldom still is it known when they have taken place:
that our reasonings concerning them have been, for the
most part, purely hypothetical; have therefore contri-
buted nothing to improve, and have often misled, the
practice of physic. In this, particularly, they have been
hurtful, that they have withdrawn our attention from,
and prevented our study of, the motions of the animal
system, upon the state of which the phenomena of dis-
eases do more certainly and generally depend. Who-
ever, then, shall consider the almost total neglect of the
state of the moving powers of the animal body, and the
prevalence of an hypothetical humoral pathology, so
conspicuous in every part of the Boerhaavian system,
must be convinced of its very great defects, and per-
ceive the necessity of attempting one more correct.

After giving this general view, it is not requisite to
enter into particulars; but, I believe, there are very lew
pages of his aphorisms in which there does not occur
some error or defect; although, perhaps, not to be
imp :ted to the fault of Boerhaave, so much as to this
that since his time a great collection of new facts has
been acquired by observation and experiment. This
indeed, affords the best and most solid reason for at-
tempting a new system: for when many new facts have
been acquired, it becomes requisite that these should
be incorporated into a system, whereby not only parti-

PPEFACE. 19

cular subjects may be improved, but the whole may be
rendered more complete consistent, and useful. Every
system, indeed, must be valued in proportion to the
number of facts that it embraces and comprehends; and
Mons. Quesney could not pay a higher compliment to
the system of Boerhaave, than by sayii.g that it exhi-
bited La medicine collective

But here it will, perhaps, be suggested to me, that
the only useful work on the subject of physic, is the mak-
ing a collection of all the facts that relate to the art,
and therefore of all that experience has taught us with
respect to the cure of diseases. I agree entirely in the
opinion; but doubt if it can ever be properly accom-
plished, without aiming at some system of principles,
by a proper induction and generalization of facts: at
least I am persuaded that it can be done not only very
safely, but most usefully in this way. This, however,
must be determined by a trial. 1 know that the late Mr.
Lieutaud has attempted a work on the plan of collect-
ing facts, without any reasoning concerning their causes:
And while I am endeavouring to give some account of
the present state of physic, I cannot dismiss the subject
without offering some remarks upon the promising Sy-
nopsis universal medicince, composed by the first physi-
cian of a learned and ingenious nation.

In this work there are many facts and much observa-
tion from the author's own experience, which may be
useful to those who have otherwise some knowledge and
discernment; but, throughout the whole work, there is
such total want of method, arrangement system, or de-
cision, that, in my humble opinion, it can be of little use,
and may prove very perplexing to those who are yet to
learn. The distinction of the genera of diseases, the
distinction of the species of each, and often even that of
the varieties, I hold to be a necessary foundation of

20 PREFACE.

every plan of physic, whether dogmatical or empirical.
But very little of this distinction is to be found in the
work of Mr. Lieutaud ; and in his preface he tells us, that

he meant to neglect such arinita sedulitas. And indeed

• i ■
his method of managing his subject must certainly in-
terrupt and retard all methodical nosology. His arrange-
ment of diseases is according to no affinity, but that of
the slightest and uninstructivc kind, the place of the
body which they happen to affect. His Generalia el
incertce sedis, have hardly any connexion at all; the
titles Rheumatisms, Hypochondriasis, Hydrops, follow
one another. When he does attempt any general doc-
trine, it is not till long after he has treated of the widely
scattered particulars. Under each particular title
which he assumes, he has endeavoured to enumerate the
whole of the symptoms that ever appeared in a disease
under that title; and this without aiming at any distinc-
tion between the essential and accidental symptoms, or
marking the several combinations under which these
symptoms do for the most part steadily appear. From
the concurrence of accidental symptoms, the variety of
the same disease is frequently considerable, a circum-
stance necessarily perplexing and distracting to young
practitioners; but it seems strange to me, that an expe-
rience of thirty years, in considerable practice, could do
nothing to relieve them.

Mr. Lieutaud has at the same time increased the con-
fusion that must arise from this want of distinction, by
his considering as primary diseases, what appear to me
to be the symptoms, effects, and sequels, of other dis-
eases only. Of this I think, the JEstus morbosus, Virum
cxolutio, Dolores, Stagnatio sanguinis, Pwulentia, Tre-
mor, Pervigilium, Raucedo, Suffocatio, Vomica, Em-
pyema, Singultus, Vomitus, Dolor Sfcmachi, Tenes-
mus, all treated of under separate titles, are examples.

PREFACE. 21

A general symptomatologia may be a very useful work,
with a view to a system of Pathology; but with a view
to practice without any System, it must have bad effects,
as leading only to a palliative practice, and diverting
from the proper efforts towards obtaining a radical cure.
Mr. Lieutaud, indeed, has endeavoured to exhibit the
symptoms above mentioned as so many primary dis-
eases: but he has seldom succeeded in this; and, in
delivering the practice, he commonly finds it necessary
to consider them as symptoms, and that not without
some theory, implied or expressed, with respect to their
proximate causes. His title of Dolores may be taken
as an example of this; and from which it may be rea-
dily perceived how far such treatises can be really
useful.

In establishing a proper pathology, there is nothing
that has been of more service than the dissection of
morbid bodies. Mr. Lieutaud has been much and most
eommendably employed in this way, and in this Sy-
nopsis he has endeavoured to communicate his know-
ledge on the subject; but in my humble opinion, he has
seldom done it in a manner that can be useful. In the
same way that he has delivered the symptoms of dis-
eases without any instructive arrangement; so on the
subject of the appearances after death, he has mentioned
every morbid appearance that had ever been observed
after the disease of which he is then treating; but these
appearances are strangely huddled together, without
any notice taken of those which belong to one set of
symptoms or to another; and with regard to the whole,
without any attempt to distinguish between the causes
of diseases and the causes of death; although the want
of such distinction is the well known ground of fallacy
upon this subject. I take for an example, the ap-
pearances mentioned as having been observed after

22 PREFACE.

dropsy. Here morbid appearances, found in every part
of (he body, in every cavity of it, and in every viscus
contained in these cavities, are enumerated: but which
of these morbid states are more frequent or more rare,
and which has been more particularly connected with
the different causes or with the different state of symp-
toms previously recited, wc are not informed, nor has
he enabled us to discover. In short, the dissection of
morbid bodies has been, and may be, highly useful ; but,
in order to be so, it must be under a different manage-
ment from what we find either in this Synopsis, or even
in the Historia Anatomico-medica.

I cannot dismiss this subject without remarking, that
the dissection of morbid bodies, is chiefly valuable upon
account of its leading us to discover the proximate
causes of diseases; and the great and valuable work of
the illustrious Morgagni is properly intitled De sedibus
et causis. It may well seem surprising, then, that
Lieutaud should find the whole of proximate causes
atra caligine mersas; and that he should never have
thought of applying his dissections towards the ascer-
taining at least some of these.

But let me now proceed to consider the important
part of every practical work, and of this Synopsis uni-
versal medicince: that is, the method of curing diseases.

Here, again, upon the same plan as in giving the
histories of disease, the method of cure is delivered by
enumerating the whole of the remedies that have ever
been employed in a disease under the title prefixed-
without assigning the species, or the circumstances to
which the remedies, though of a very different and
sometimes opposite nature, are particularly adapted. On
the subject of Asthma, he very justly observes that phy-
sicians have been to blame in confounding, under this
title, almost all the species of Dyspnoea; and he himself

PREFACE. 23

very properly considers Asthma as a disease distinct
from all the other cases of Dyspnoea. Still, however, he
considers Asthma as of many different species, arising
from many different causes, which till we understand
better, we cannot attempt to remove. Notwithstanding
all this, he proceeds to deliver a very general cure.
Parum abest, says he, quia specifici titulo gaudeant pec-
tor alia, vulneraria, et incidentia! But from such lan-
guage I receive no clear idea; nor can I obtain any
clear direction from the enumeration of his medicines.
Baccce juniperi, gummi, tragacanthum vel ammonia-
cum, sapo aqua picea, terebinthina, fyc. quae tamen
haud indiscriminatim sunt usurpanda, sed pro re nata,
dcluctu opus est Very justly, indeed, deluctu opus est;
but here, as in many others instances, he gives us no
sort of assistance.

From his endeavours, though not always successful,
to neglect all system, his practice is generally delivered
in a very indecisive manner; or, what has the same
effect, in a way so conditional as will render it always
difficult, and often impossible, for a young practitioner
to follow him. Let us take, for example, his cure of
Dropsy. " The cure may be begun by blood-letting in
certain conditions; but in others, it cannot be employed
ivithout danger. It gives relief in difficult breathing;
but, after it is practised, the symptoms are aggravated,
and rendered more obstinate. It is not to be concealed
that some persons have been cured by repeated blood-
lettings, or spontaneous haemorrhagies; but it is at the
same time known, that such a remedy inopportunely
employed, has in many instances hastened on the fatal
event."

In the same manner, he treats of vomiting, purging,
sweating, and the use of mineral waters; but I must
confess, that he has no where removed any of my

24 PREFACE.

doubts or difficulties, and indeed he has sometimes in-
creased them. He says, that hepatics, or aperients, such
as the lingua cervina, herbce capillares, fyc. deserve com-
mendation; but that when the disease has arisen to a
certain degree, they have been, for tke most part, found
to be useless. He observes, that the powder of toads
given in wine, to the quantity of a scruple or more, has
succeeded with severals.

Such are commonly the methods of cure delivered
by Mr. Lieutaud, longiori et forte felicissima praxi
edoctus.

It would be tedious to enter further into that detail,
which a criticism of this immethodical and uninstruc-
tive work might lead me into; but, if the bounds pro-
per for this preface did not prevent mc, I would parti-
cularly show that the work is far from being free from
those reasonings which the author pretends to avoid,
and would affect even to despise. He still holds the
doctrines of the concoction and critical evacua-
tion of morbific matter; doctrines depending upon
subtile theories, and which, in my opinion, can in no
wise be ascertained as matters of fact. Mr. Lieutaud
likewise is still very much upon the old plan of follow-
ing nature, and therefore gives often what I consider
as a feeble and inert practice. The hamectantia, dilu-
entia* demidccntia, et tcmperantia, are with him very
universal remedies, and often those which alone are to
be employed.

The mention of these medicines might lead mo to
take notice of Mr. Lieutauds second volume, in which,
ab insula remediorum farragive alienus, he promises a
great reformation upon the subject; but this fails so far
short of the idea of British physicians, that I need not
make any remarks upon it. With respect to his list of
simples, or Emporetica, as he is pleased to term them.

PREFACE. 25

an English apothecary would smile at it; and with re-
spect to his Officinalia, I believe they are to be found
no where but in the Codex Medicamentarias of Paris;
and in his Magistralia his doses are generally such as
the most timid practitioner of this country would hardly
descend to; and such as none of our practitioners of
experience would depend upon. In short, the whole
of the work, both with respect to the theories with
which it abounds, and to the facts which it gives, will
not, in my apprehension, bear any serious criticism.
But I must conclude; and shall only say further, that
such as I have represented it, is this work, executed
by a man of the first rank in the profession. It is in-
deed for that reason I have chosen it as the example
of a work, upon the plan of giving facts only, and of
avoiding the study, or even the notice of the proximate
causes of diseases; and with what advantage such a
plan is pursued, I shall leave my readers to consider.

In the following treatise I have followed a different
course. I have endeavoured to collect the facts relative
to the diseases of the human body, as fully as the nature
of the work and the bounds necessarily prescribed to it
would admit; but I have not been satisfied with giving
the facts, without endeavouring to apply them to the
investigation of proximate causes, and upon these to
establish a more scientific and decided measure of cure.
In aiming at this, I flatter myself that I have avoided
hypothesis, and what have been called theories. I have,
indeed, endeavoured to establish my general doctrines",
both physiological and pathological ; but I trust that
these are only a generalization of facts, or conclusions
from a cautious and full induction ; and if any one shall
refuse to admit, or directly shall oppose, my general
doctrines, he must do it, by showing that I have been
deficient or mistaken in assuming and applying facts. I

vol. i. T)

26 PREFACE.

have, myself, been jealous of my being sometimes im-
perfect in these respects; but I have generally endea-
voured to obviate the consequence of this, by proving,
that the proximate causes which I have assigned, are
true in fact, as well as deductions from any reasoning
that I may seem to have employed. Further, to obviate
any dangerous fallacy in proposing a method of cure, I
have always been anxious to suggest that which, to the
best of my judgment, appeared to be the method ap-
proved of by experience, as much as it was the conse-
quence of system.

Upon this general plan I have endeavoured to form a
system of physic that should comprehend the whole of
the facts relating to the science, and that will, I hope,
collect and arrange them in better order than has been
done before, as well as point out in particular those
which are still wanting to establish general principles.
This which I have attempted may, like other systems,
hereafter suffer a change; but I am confident that we
are at present in a better train of investigation than phy-
sicians were in before the time of Dr. Hoffman. The
affections of the motions and moving powers of the ani-
mal economy, must certainly be the leading inquiry in
considering the diseases of the. human body. The in-
quiry may be difficult; but it must be attempted, or the
subject must be deserted altogether. I have therefore
assumed the general principles of Hoffman, as laid down
in the passage which I have quoted above ; and if I have
rendered them more correct, and more extensive in
their application ; and more particularly, if I have avoid-
ed introducing the many hypothetical doctrines of the
Humoral Pathology which disfigured both his and all
the other systems which have hitherto prevailed; I hope
I shall be excused for attempting a system, which upon
the whole may appear new.
Edinburgh, Nov. 1789.

PRELIMINARY DISCOURSE,

BY THE EDITOR.

WERE it not for the measures of unrelenting hosti-
lity prosecuted for years, by a late distinguished teacher
in the University of Pennsylvania, for the overthrow of
systematic and classical medicine, we could have no
plea for wishing to occupy any portion of the time of
our readers in attempting its defence. For more than a
century preceding the commencement of this war of
extermination, thus openly and formally declared
against it, Methodical Nosology had been considered as
resting on the immoveable basis of reason, experience,
and the unqualified approbation of every enlightened
physician of the time. It had been regarded as a
branch of medicine originating in necessity, sanctioned
by utility, and founded in the immutable nature of dis-
ease. But ingenuity and sophistry may become dan-
gerous weapons in any department of practical science.
When employed by ambition, and wielded by a daring
spirit of innovation, they are capable of spreading dark-
ness, for a season, around the brightest truths, and giv-
ing a temporary lustre to the wildest hypotheses.

When we recollect the high and imposing rank of
the professor to whom we have just alluded, and add to
this, the formidable power and extent of his means,
against such opinions as he wished to destroy — placed,

28 PRELIMINARY DISCOURSE.

as a practitioner, at the head of his profession, acute
and ingenious as a writer, eloquent and unusually
popular as a teacher, zealous and indefatigable in his
favourite pursuits, and possessing, through the medium
of his lectures and writings, opportunities peculiar to
himself for ensuring a wide dissemination of his doc-
trines — when we call to mind these considerations, and
subjoin what our own observation has taught us, we
can no longer doubt, that, in relation to the truth and
usefulness of systematic nosology, the belief of hun-
dreds has been seriously shaken — that dangerous he-
resies have been abundantly infused into the minds of
many of the physicians of the United States, and that,
on practical no less than scientific grounds, the interest
of medicine calls for their removal. Such are the evils
which, in professional science, can scarcely fail to re-
sult from the labours of distinguished individuals who
unfortunately mistake alteration for improvement, and
innovation for reform.

To aid, to the extent of our humble means, in the
eradication of those errors, which have thus been im-
planted in a portion of the medical mind of our country,
and in the restoration of certain rejected doctrines, of
the soundness of which we have not ceased to be per-
suaded, and the cause of which we have never abandon-
ed, constitutes the principal object of this discourse.
To render it as conclusive as possible, and to bestow
on it somewhat of an elementary and didactic charac-
ter, we shall attempt, in the course of it, an analytical
view of the grounds and principles of classical arrange-
ment.

The true basis of system and classification in science
is, affinity in some points, and dissimilarity in others;
their object and tendency, to facilitate the acquisition
of knowledge, by compressing what is scattered, sim-

PRELIMINARY DISCOURSE. 29

plifying and rendering clear what is dark and intricate,
and reducing to order what is irregular and confused.
Such are their effects in Natural History at large, and
its subordinate branches. Zoology and Botany, Geology
and Mineralogy; and such are also the aids they afford
in the study of Metaphysics and Chemistry, Philology
and Moral Science; such, in fact, are the helps and faci-
lities which they alone can bestow on those who are in
pursuit of general knowledge.

Without the advantages of systematic arrangement,
every field of research, whether natural or moral, meta-
physical or literary, would remain in the condition of
an uncultivated waste, marked by the footsteps of dis-
order and barrenness. The sunshine of real science
could never quicken it, nor could the hand of industry
render it fruitful. The adventurous explorer might in-
deed pass through it, and be, in no small degree, de-
lighted with the novelties around him: he might even,
for a time, fancy himself instructed; but every thing
being blended without regularity or order, nothing
would present itself to him in its true relations: hence,
his recollection of all he had seen being indistinct and
confused, his labours would be unprofitable to those
who might follow him. He could leave behind him
scarcely a track or a beacon for the direction of their
course.

A branch of science under the influence of correct
classification and arrangement, resembles a stately edi-
fice, complete in its parts, just in its proportions, har-
monious in its composition, chaste in its ornaments,
and capable of being compassed, in all its beauties, at
a single view. Deprived of its classification, the same
branch may be fitly compared to the same building
shaken from its basis, and reduced to a shapeless pile
of ruins, by a hurricane, an earthquake, or the opera-

30 PRELIMINARY DISCOURSE.

tions of war. It is now a mass of confusion, in which
all affinity, and every principle of association are want-
ing; or, if not actually wanting, incapable of being
traced by the common observer: it cannot be viewed
in its several parts without an examination that is pain-
fully laborious: and, even then, it is seen only in de-
tached parcels, to offend by its unsightliness, distract,
and be forgotten.

That we may be the better understood, let Zoology
be the branch of science selected to illustrate and ex-
emplify our meaning. Within the same inclosure let
us suppose to be crowded together, without order or
arrangement, individuals or pairs of all the several
species of animated beings that the earth contains —
man and quadrupeds, birds and fishes, reptiles and in-
sects, shells and zoophytes.

What a vast and incomprehensible scene of confusion
the fancy here presents to our view! There appears
to exist in it no common bond of union, nor any clue of
affinity or resemblance, to lead us from a knowledge of
one object to that of another, until the whole shall be-
come familiar to us. On taking a survey of it, what
observer would conceive himself capable of ever dis-
tinctly remembering, and referring to, as a source of
useful knowledge, the many thousands of jarring and
heterogeneous individuals of which it is composed?

Jjet this living chaos, however, but feel the touch of
an enlightened Naturalist — let it be divided, according
to strict systematic arrangement, into the classes, or-
ders, genera, and species of which it is composed, and
each species be placed next to that to which it bears
the closest resemblance — let this be done, and imme-
diately all confusion, and difficulty of comprehension
are at an end. Every little group of beings exhibiting
now an affinity to those around it, a chain is perceived

PRELIMINARY DISCOURSE. 31

which binds together in one great alliance the whole
assemblage; while a clue is presented to the inquirer,
calculated to lead him, by easy and natural gradations,
from the knowledge of one part to that of another,
until a perfect familiarity with the whole shall be at-
tained. He no longer examines the multitude before
him by individuals: he looks at it now by families or
tribes, and learns, in a short time, to compass the whole
at a single glance.

It is thus that, in our progress through the rudiments
of learning, we proceed from letters to syllables, from
syllables to words, and from words to sentences, until a
whole page is deciphered almost as soon as it meets the
eye — so essential is the aid which classical arrange-
ment affords us, in our pursuit of the knowledge of
Zoology and letters. Nor is it less useful to us, as might,
by analysis, be fairly demonstrated, in the study of any
other branch or topic of science.

It is true that Dr. Rush, whose opposition to metho-
dical Nosology led us to engage in the composition of
this discourse, acknowledged the general utility of clas-
sical arrangement, but denied its applicability to the
science of disease. It will appear, however, we appre-
hend, on an examination of the subject, that his rea-
sons for this denial were without weight.

We have already observed, that the only true basis
for a classical arrangement of objects, to whatever de-
partment of nature they may belong, is a permanent and
perceptible affinity between them in some points, and a
dissimilarity in others. We shall now add, that all ob-
jects, thus relatively characterized, are susceptible of
such arrangement.

Is this definition applicable to diseases? Are the va-
rious morbid phenomena to which the system of man is
liable, so marked in relation to each other, as to be

32 PRELIMINARY DISCOURSE

plainly and uniformly similar in some points, and dissi-
milar in others? If so, they are, in their nature, as
susceptible of a methodical arrangement, as the objects
of the animal and vegetable kingdoms.

To physicians of experience, observation and thought,
this topic of inquiry must be already sufficiently clear:
to the inexperienced but sensible student of physic, we
trust there will be found but little difficulty in render-
ing it so.

The human body is known to be a compound ma-
chine, consisting of various subordinate parts, which
differ not a little from each other in their structure, func-
tions, and uses. Of these parts it will be sufficient for
our present purpose to enumerate, the skin, the muscles,
the brain and nerves, the heart and blood-vessels, the
absorbents, the glands, the stomach and alimentary ca-
nal, and the bones.

It is further known that these subdivisions of the
body are susceptible of disease, either severally in par-
cels, or all at once. The latter, however, is a phenome-
non which does not, perhaps, very often occur. An uni-
versal disease, in which no part of the system escapes,
we have rarely witnessed.

The whole, or a great proportion of the body may
be also diseased, in a certain degree, while a still higher
and severer complaint exists in some one of the subor^
dinate parts. This is more especially the case in Dr.
Cullen's Order Phlegmasiae. But the same thing is also
true of all febrile diseases that are accompanied with
a topical affection — of the Exanthemata, the Hemor-
rhagise, the Profluvia., and even many of the class Neu-
roses.

As all the subordinate parts of the body differ from
each other essentially in their structure, functions and
uses, it follows, of absolute necessity, that they must

PRELIMINARY DISCOURSE. 33

be subject also to different diseases.* They are not
organized alike; they act, and, whether sound or un-

* This is true not only of the various organs of the body, but of the dif-
ferent structures of which they are composed.

The primitive structures are four, the serous, the mucous, Xheji/jrous, and
the cellular, each differing from the other in its organization, its susceptibi-
lity, and its power of action.

This lays the foundation for a radical difference in the character of dis-
ease, according to the structure in which it is seated.

Diseases are essentially modified by the powers of action of the parts
they attack. Even when they both proceed from the same cause, a com-
plaint situated in a mucous, differs materially from one that has its seat in a
serous membrane, while, if it attack a fibrous or a cellular structure, it ex-
hibits still a further difference.

Catarrh and pleuritis vera are both inflammatory complaints, and often
arise from the same cause. But they are exceedingly different in their cha-
racter, because the former is seated in a mucous, and the latter in a serous
membrane.

For the same reason dysentery and diarrhoea differ widely from enteritis,
and gonorrhoea from an inflammation of the peritoneum or the skin.

Rheumatism and colic are affections of the Jibrous, and differ essentially
from phlegmonic inflammation, and every other disease that has its seat in
the cellular structure. '

But it is not on the difference of structure alone that disease depends for
its immense variety. It is modified in a still higher degree by the differ-
ence of its causes.

Disease is the result of morbific stimulation on some portion of the body.
But all stimulants are, in their nature, essentially different from each other.
They are all, in the strict sense of the term, specifics, and produce, when
applied to living matter, each a kind of action corresponding with its own
peculiar character.

The matter of small-pox is essentially different from that of measles, the
matter of bilious from that of typhus fever, and the matter of syphilis from
that of kine-pox, while, between all the animal, vegetable, and mineral poi-
sons, whether veriform or fixed, similar differences are known to obtain.

Considering, then, the existence of two such powerful and prolific
sources to give diversity to disease, how infinitely preposterous is that doc-
trine, which proclaims its " unity !" No less wild and unwarrantable would
it be to assert the unity of the vegetable kingdom!

When human physiology shall have been better understood, important
improvements in the practice of medicine will arise out of a perfect know-
ledge of the susceptibilities and sympathies of the four primitive structures
of which the body is composed.

It will then be fully known, as it is now in part, that those structures are
specifically impressed by agents specifically different from each other, and
tbat each structure has a peculiar affinity or aptitude to be acted on by its
own kindred class of remedies.

VOL. I. E

S4 PRELIMINARY DISCOURSE.

sound, must act, in a manner corresponding to their
organization; disease is the morbid action of organized
parts; their diseases, therefore, cannot be alike.

Without any further reasoning to support it, this po-
sition might be assumed and rested on as a physical
axiom. To the enlightened pathologist it is a self-evi-
dent truth. As well may the mechanic look for the
same kind of action, whether sound or disordered, in
a steam-engine and a watch, a water-mill and an orrery,
however dissimilar these productions of art may be in
their structure, as the physician in the different subdi-
visions of the body.

This point being exceedingly important to the deci-
sion, and even to the proper understanding of the pre-
sent controversy, we shall, for the more satisfactory
illustration of it, dwell on it further, and treat of it more
in the form of analytical detail.

The structure and the healthy action and functions
of the skin and muscles being radically different from
each other, because they are intended to subserve, and
do subserve, different purposes in the animal economy,
it is physically impossible that their diseased action
should be the same. — Nothing short of a miracle —

Thus terebinthinales manifest a specific predilection for the mucous
structure. Hence their salutary effects in catarrh, gonorrhoea, fluor albus,
and other complaints of a similar character.

On the fibrous structure, act with a specific effect narcotics and antispas-
modics; while sudorifics and diuretics throw their influence more especially
on the serous structure.

These latter articles act also, to a certain extent, on the cellular struc-
ture. Touching specific remedies, however, for the structure, we do not
profess to speak with certainty.

From considerations contained in this note, we feel persuaded, that fu-
ture improvements in the practice of medicine are destined to arise, not
out of additions to be hereafter made to materia medica, but from the admi-
nistration, or correct principles, of the remedies we possess.

All medicinal substances are, in their nature, specifics, and, to do the good
of which they are capable, must be administered under a knowledge, not
merely of their general operation, but of their specific effects.

PRELIMINARY DISCOURSE. 35

something, at least, subversive of the usual processes
of nature — could render them so. Simply to state this
position is definitely to prove it. Arguments would be
wasted in an attempt to elucidate or strengthen it. No
man of a sound intellect will expect to find the same
disorder in the rigging of a ship and the wheels of a
clock. The reason is obvious. The machinery is dif-
ferently constructed, because designed for different pur-
poses. The disorders incidental to it must be also dif-
ferent. So in relation to all conditions of the skin and
the muscles of the human body. Their action, whe-
ther diseased or sound, cannot be alike, because the
organic structure of the parts is dissimilar.

The same thing is true with respect to the heart and
blood-vessels, and the brain and nerves. The organiza-
tion and healthy action of these parts are utterly dissi-
milar; so also are their uses: it would be contrary,
therefore, to every principle of reason, and every esta-
blished rule of philosophizing: to allege that their dis-
eases can be alike. They must be different, or nature
is palpably inconsistent with herself.

Who will be so weak as to assert that the same kind
of disease can prevail in the intestines and in the bones?
— in an absorbent and in the optic nerve? — in a gland
and in the nerve of hearing? — parts so fundamentally
different from each other, not only in structure, but in
all the attributes and properties of life. With equal rea-
son and probability of success might an attempt be made
to maintain the identity of a man and an elephant, or a
lion and a whale.

Thus might we examine in detail the whole of the
human system, and show, that from a necessity as in-
flexible as the principles of nature, different parts of it
must be subject to different diseases. To maintain the
contrary would be to pronounce causes, totally dissimi-

36 PRELIMINARY DISCOURSI-

lar in their principles and modes of action, capable of
producing similar effects.

A disease consists in the suspension or disorder ot
one or more of the functions of the body. It must be
widely different, therefore, in different instances, ac-
cording to the function thus affected.

An unsound state of the functions of the lungs pro-
duces a disease widely different from that which arises
from an unsound state of the functions of the stomach.
If the functions of the liver be disordered, the disease
is equally different from that which a disorder in the
functions of the kidneys excites. Nor, when the func-
tions of the eye are shattered or destroyed, will any one
contend that the disease is the same with that which
results from a similar affection in the functions of the
ear. These are truths so nearly self-evident, that, un-
supported by the weight of argument or authority, they
may be safely left to defy the devices and powers of
sophistry. The extent to which they might be mul-
tiplied by a further analysis, will be readily perceived
by the enlightened pathologist. They might be render-
ed as numerous as the several organs or parts of the
body, which differ from each other in their functions
and uses.

A very fertile source of difference between the dis-
eases of the several organs of the body, arises from the
different sympathies which these organs possess with
the system at large. A local affection of the stomach
produces a disease widely different from a similar af-
fection of the lungs, because the sympathies of the two
organs are equally different. The uterus possesses
sympathies with the rest of the system different, in a
high degree, from those of the liver: the affections of
these two organs, therefore, cannot be alike in their
nature or consequences. The same thing might be

PRELIMINARY DISCOURSE. 37

said of the kidneys and spleen, the brain and heart, and
of various other organs of the body, were it necessary
to enumerate them.

The diseases to which we have, as yet, had reference,
must be regarded as somewhat limited in their extent.
The dissimilarity between those of a more general cha-
racter may be demonstrated with equal facility and
certainty.

A febrile disease cannot fail to be different in its na-
ture and character, according to the part of the system
in which it is radicated, and on which it expends its
principal force. A fever having its topical affection in
a vascular part, is necessarily different from one which
topically attacks the brain or nerves. In other words, an
inflammatory is different from a nervous or typhus fe-
ver. Equally different is a fever radicated in the sto-
mach from that which throws the force of its action on
some of the glands or the skin: while those invading
the bowels, or commencing there in the form of diar-
rhoea, and in that portion of the Schneiderian mem-
brane which lines the fauces and the bronchiae, are
different from both.

Thus far we have reasoned a priori; or, in language
less technical, from first principles; and hope that our
arguments have neither been unsound, nor our conclu-
sions illegitimate.

But perhaps we might most decisively establish our
position, by somewhat inverting ouf rule, and, instead
of merely inferring the diversity of diseases from the
existing diversity in the nature of their seats, prove it
from the difference of their signs and symptoms.

The more, clearly to demonstrate the fairness of our
reasoning, we shall iiere premise, that, from an acknow-
ledged inability to penetrate the nature or essence of
things, we are forced to judge of them from external

38 PRELIMINARY DISCOURSE.

appearances. Nor can we pretend, in general, to the
slightest knowledge of them, except what these appear-
ances communicate. To illustrate our meaning by a
familiar example.

• In pursuing our studies in the science of nature, out-
ward appearances constitute our principal, in most in-
stances, our only guides to knowledge. We are, there-
fore, compelled to have recourse to their aid, and to
place confidence in the truth of the information they
impart. Henpe it is, that where we find objects uni-
formly different in their external qualities, we are for-
bidden to doubt that they are different in themselves.
While, on the other hand, the only evidence we can
possess of actual identity, is identity of appearance.

To be still more explicit on this subject. When we
find two objects — vegetables, for example — the same in
size, in figure, in colour, in blossom, in fruit, in habit,
in smell, and in taste, we conclude, without hesitation,
that they are the same in species. Nor is there any one
so hardy as to call in question the correctness of our
decision. The same thing is true in relation to subjects
of the animal and mineral kingdoms. Identity in all their
discoverable qualities is received as evidence of identity
in their nature. The reverse of this rule is equally un-
questionable. An invariable difference in the qualities
herein specified is regarded as indicating conclusively a
difference in the genera or species of animals, vegetables,
and minerals.

By enlightened pathologists the same rule of investi-
gation is admitted as perfectly applicable to diseases. In
common with the regular productions of nature, these
morbid conditions of the body can be studied only
through the medium of their phenomena or external
qualities. But the only external qualities which they
possess are their signs and symptoms. A sameness in

PRELIMINARY DISCOURSE. 39

these manifests a sameness of origin, while an invari-
able difference in them never fails, nor can it, indeed,
fail, to be received as evidence, satisfactory in itself, of
a radical difference in the nature of the diseases to
which they belong The same disease can no more
exhibit different phenomena or characteristic symptoms,
than the same plant can exhibit a difference in its own
fruit and figure, its flowers and foliage.

These truths are already so clear, that, by those who
are versed in the science to which they belong, an at-
tempt to render them more so might be deemed super-
fluous. They are a fair and perspicuous interpretation
of the language of nature, in relation to the subject
whereof we are treating. But in a case where funda-
mental principles are concerned, nothing should be left
to fancy or conjecture. We deem it our duty, there-
fore, to adduce a few examples illustrative, and, at the
same time, confirmatory of the doctrine for which we
are contending.

According to the correct rule of philosophizing, a
febrile disease marked with an acute pain in the thorax,
a difficulty of respiration, a violent cough, and a frothy,
puriform, or sanguineous expectoration, is essentially
different from a case of fever unaccompanied by such
topical affection; much more does it differ from one,
which, to an exemption from any local thoracic com-
plaint, adds a general pustulous eruption on the surface
of the body. For the reason why these diseases must
be pronounced different no one can be at a loss. It
is because their perceptible and characteristic qualities,
from which alone we derive our knowledge of them,
are essentially different. Nor can any thing induce us
to consider them the same, unless it be some delusive
hypothesis, which fairly cheats us of the testimony of
our senses.

40 PRELIMINARY DISCOURSE.

On no ground of evidence or principle of reason can
a disease marked by tormina or severe gripings, a con-
stant and distressing tenesmus, frequent mucous, puri-
form, or bloody discharges from the bowels, and pro-
duced by an exposure to atmospheric impurities, be
considered the same with one arising from a puncture
in the foot or hand, and characterized by an immobility
of the lower jaw, a stitfness of the neck, a difficulty of
swallowing, a constipation of the bowels, a distressing
pain in the epigastric region, and general convulsions
frequently recurring, or an entire rigidity of the body
and limbs. The discriminating characters of a horse
and a lion, or of a serpent and a dog, are not more
strikingly perceptible, nor more widely different from
each other, than those winch mark the distinction be-
tween these two diseases. Nothing, therefore, short
of absolute ignorance in medicine, or some profession-
al hallucination bordering on madness, can induce any
one to pronounce dysentery and tetanus to be the same
disease.

Observations precisely similar may be made in rela-
tion to scrophula, which is an affection of the glands,
and erysipelas, which is a peculiar inflammation of the
skin; diarrhoea, a complaint of the bowels, and regular
gout, which is topically seated in the foot; rheumatism
a disease confined to muscular, ligamentous, or other
soft parts, and rickets, which perpetrates its ravages on
the bones. The peculiar marks, by which alone these
several diseases can be known, are essentially different
from each other. It is a disregard of evidence, there-
fore, amounting to a breach of moral obligation, seri-
ously to contend that the diseases are the same.

By passing, in this manner, through the whole cata-
logue of diseases comprised in the systems of judicious
nosologists, we might show that they are all distinguish-

PRELIMINARY DISCOURSE. 4]

ed from each other by characters sufficiently percepti-
ble and definite, to be recognized by every one, and to
answer the purposes of a classical arrangement.

Before taking leave of this head of our subject we
shall further observe, that whatever set or family of
morbid symptoms we find associated together with a
constancy and regularity that do not belong to accident,
but comport with the steadiness of a law of nature, we
are bound to consider as arising from a common and
distinct cause, and as constituting necessarily a separate
disease. Should this association of symptoms be py-
rexia, ushered in by a harsh, dry and sonorous cough,
and a red and watery state of the eyes, with an occa-
sional sneezing, and succeeded on the third or fourth
day by a scarlet-coloured eruption on the skin, we give
it the name of measles: if it be a preternatural dulness
and disinclination to motion, heartburn, nausea and an
occasional vomiting of an acid gelatinous fluid, a cos-
tive state of the bowels, an unusually light colour of
the faaces, and a yellowness of the skin, accompanied
at times with a troublesome itching, we regard it as
constituting a different disease, and call it jaundice:
and if it be a severe pain of the bowels, with a sensa-
tion of twisting or knotting in the region of the navel,
marked by occasional intervals of ease, and attended
by obstinate costiveness and vomiting, we term it colic.
It is thus that in the animal and vegetable kingdoms,
we regard certain uniform and regular combinations of
the external qualities of size, form, habit, colour, odour,
and taste, as constituting distinct classes and orders, ge-
nera and species.

Having, as we flatter ourselves, satisfactorily establish-
ed, in relation to diseases, one branch of the basis of a
classical arrangement, viz. their radical difference from
each other, it belongs to us now to make a few remarks

vol. j. F

12 PRELIMINARY DISCOURSE.

on their affinities, which constitute, as we have already
observed, the other branch. On this head oi" our sub-
ject it is our intention to be brief; a detailed anal) sis
of it being altogether unnecessary for the purposes we
have in view.

One circumstance which constitutes a point of strong
analogy between the diseases we are considering is,
that they are all incidental to the system of man. They
consist, moreover, in a disorder, suspension, or entire
destruction of one or more of the functions of health,
and are accompanied with an increase or diminution of
action and sensation, and a preternatural condition of
muscular strength. Certain families or tribes of them
commence with a chilliness, and an enfeebled state of
the pulse, which are, in a short time, succeeded by in-
creased arterial action, and inordinate heat. Of these,
some assume a continued form; others exhibit regular
periodical intermissions; some are free from any topical
affection; others are marked by acute and violent pains
in various parts of the body; a fifth order are accompa-
nied with discharges of blood; and a sixth with various
eruptions on the skin.

As further points of affinity between certain tribes or
families of diseases may be mentioned, preternatural
discharges of fluids not sanguineous, disordered and
irregular contractions of certain sets or systems of
muscles, and an intumescence of various parts of the
body.

Sundry other marks of affinity might be here enume-
rated; but the foregoing, we trust, will serve to show,
that diseases are related to each other by ties sufficiently
strong and diversified, to furnish ground for an associa-
tion of them under a system of classical nosology.

We might now proceed to speak of that plan of no-
sological arrangement which appears most natural in

PRELIMINARY DISCOURSE. 43

itself, and best comports with the character of diseases.
But it will, perhaps, be expected, that we should pre-
viously take some notice of the objections urged by Dr.
Rush against systematic nosology in general, and of his
attempt to repudiate it from medical science.

The objections of that celebrated teacher, in relation
to this subject, might seem to have been numerous:
but, when considered on principle, they are reduced to
a point : they all derived their origin from a single
source — the belief of their author in the unity of disease.
Had it not been for the influence of that hypothesis, the
professor would never have rejected classification, and
renounced nosology. He possessed too correct a know-
ledge of the value of system, and held in too high esti-
mation arrangement and method, to have pursued, as
the result of cool deliberation and an unbiassed judg-
ment, a course of inflexible hostility to that, which alone
brings order out of confusion and renders medicine in-
telligible.

But we ought, perhaps, to recal our expression. Dr.
Rush did not, in reality, renounce nosology. His re-
nunciation was in words, not in fact. He only ex-
changed one plan of nosology for another — a more sim-
ple, as we conceive, for a more complicated — a sub-
stantial for a visionary — one founded in nature, or, at
least, corresponding with many of the phenomena of
disease, for one which appears to have been much more
the creature of fancy than of reason.

The nomenclature of diseases used by Dr. Rush,
which was, in many instances, exceedingly forced and
unnatural, was nothing but a substitute for a scheme
of nosology. By a brief and fair analysis of the sub-
ject, this may be proved to the satisfaction of the
reader.

To place this matter beyond the sphere of denial or

44

PRELIMINARY DISCOURSE.

doubt, we will here give a comparative view of a por-
tion of the nomenclatural arrangement of Dr. Rush,
and the corresponding part of the nosological arrange-
ment of Dr. Cullen. We shall begin with the differ-
ent kinds, or, as Dr. Rush denominates them, states
of fever, and, for the sake of discrimination, shall affix
over each arrangement the name of its author.

CULLEN.

1. Intermittent fever.

2. Synocha.

3. Typhus mitior.

4. Typhus gravior.

5. Typhus Icterodes.

6. Synochus.

7. Hectica.

RUSH.

1. Synochus fortis.

2. Synocha.

3. Synochula.

4. Synochoid.

5. Synochus mitis.

6. Intermittent.

7. Hectic.

8. Typhoid.

9. Febricula.

10. Suffocated or oppressed
state.

1 1. Prostrate state.

12. Gangrenous state.

Another suitable specimen of comparison may be
derived from the nomenclature and arrangement of the
diseases of the mind.

CULLEN.

VeSANIjE THE NAME OF THE

OltDER.

1. Amentia.

2. Melancholia.

3. Mania.

4. Oneirodynia.

RUSH.
Diseases of the Mind.

1. Seatou Mania.

2. Allou Mania.

3. General mania in its high-
ly inflammatory state.

4. Manicula.

5. Manalgia.

6. Fatuity.

7. Defect and lossof memory.

8. Dreaming.

9. Phantasms.

10. Absence of mind.

11. Operations of the mind in
a trance.

We shall close this comparison with a view of certain
diseases deriving their names from the parts of the
body they particularly affect.

PRELIMINARY DISCOURSE.

45

CULLEN.

RUSH.

(xastrilis.

1. Gastritic state of fever

2. Enteritis.

2. Intestinal.

3. Hepatitis.

3. Hepatic.

4. Diabetis.

4. Diabetic.

5. Haemorrhois.

5. Hemorrhoidal.

6. Cystitis (Inflammation of

6. Cystic.

the bladder.)

7. Ophthalmic.

7. Ophthalmia.

8. Odontalgic.

8. Odontalgia.

9. Otalgic.

9 Otalgia.

10. Apthous.

10. Apthae.

1 1. Scrophulous.

1 1. Scrophula.

12. Scorbutic.

12. Scorbutus (scurvy.)

13. Convulsive.

13. Convulsions.

14. Hydrophobic.

14. Hydrophobia.

15. Hysterical

15. Hysteria.

16. Hypochondrical.

16. Hypochondriasis.

17. Cutaneous.

Of this comparative statement, the tendency and re-
sult are too obvious in themselves, to require for their
illustration the slightest comment. They show with a
clearness amounting to demonstration, that Dr. Rush
has neither rejected, nor, in any one respect, improved,
nosological arrangement. Or, if he has improved it, it
is not by abridging and simplifying it, but by rendering
it more complex and voluminous.

Under the order of Fevers, properly so called,
Dr. Cullen has enumerated seven kinds, and Dr. Hush
twelve.

The latter has eleven different kinds or forms of dis-
eases of the mind, and the former only four.

In the last instance of comparison, although the dis-
eases on which the two professors have bestowed names
are very nearly equal in number, Dr. Cullen is in no re-
spect inferior to Dr. Rush in perspicuity of expression,
and surpasses him not a little in classical brevity. His
system is therefore entitled to a preference.

Doctor Rush, in his nomenclature, expressly recog-
nized the affinity of diseases. In his hydropic state of
fever, his pneumonic state, his rheumatic state, his

46 PRELIMINARY DISCOURSE.

hepatic state, his cephalic state, and many others, the
affinity consists in their being all possessed of a febrile
character. But he, also, as expressly recognized their
differences. These consisted in the difference of their
determinations or topical affections. Were they not, in
this respect, different, why designate them by different
names? The measure, had he believed them to be the
same, would have been altogether unwarrantable; be-
cause it would have been giving sanction and currency
to an error.

It is true, he professes to consider these complaints as
different farms of disease, instead of actually different
diseases. But the distinction which he here attempts to
establish, consists in words, not in substance. Perma-
nently different forms of disease, occurring under differ-
ent circumstances, occupying different seats, exhibiting
different symptoms, attended with different degrees of
danger, and requiring different modes of treatment, are
as capable of being classed, as if they were specifically
different diseases. Indeed, in .relation to all practical
purposes, they are different diseases, and may, with
propriety, be so denominated.

Form is a quality so striking and attractive, and, in its
relationship to every thing of which we have any know-
ledge, so perfectly essential, that it alone is capable of
constituting a radical and characteristic difference.
This may be proved by innumerable examples.

In what but form does a triangle differ from a square,
an acute angle from an obtuse, a cone from a parallelo-
gram, or an ellipsis from a circle ? In what else does a
dagger differ from a sword, a bayonet from the point of
a spear, or a trumpet from a French horn ? In what other
than form does the body of a horse differ from that of
an ox, the body of a dog from that of a goat, or the body
of a lion from that of a tyger? — or, more forcible still, in

Preliminary discourse. 47

whst but fcm doe- the boHy of a man differ from either?
We answer, in nothing that is by any means so important
as form. Yet all these objects are capable of being
clearly discriminated from each other, and methodically
arranged in well defined classes, orders, and genera.

Such precisely is the case in relation to diseases. To
the mind of a pathologist, what Dr. Rush calls the hepa-
tic state of fever, presents an image very perceptibly
different from that presented by his pneumonic state —
an image that can be realized and felt as a distinct ex-
istence, with as much facility as can that of an oak or an
eagle. With equal ease may the hydropic state of fever
be discriminated from the rheumatic, the cephalic from
the nephritic, and the gastritic from the ophthalmic. Had
not this been the case, the doctor would have been guilty
of the fault of using names without a meaning. These
diseases, or, in the professor's own language, forms of
disease, are, moreover, perfectly susceptible of classifi-
cation and arrangement ; their affinities consisting in
their febrile character, and their diversities in their
topical affections, and the peculiar symptoms which
these affections respectively produce.

But, disregarding, for the present, his minor positions,
we shall approach, at once, the stronghold of Dr. Rush's
opposition to systematic nosology. This, as already
stated, is his doctrine of the unity of disease — the con-
viction of his own mind, with his arguments in support
of it, that all diseases are essentially the same.

If this main ground of his opposition, the citadel of
his strength, can be taken from him, and shown to be,
in its nature, utterly untenable, his posts and outworks
established for its defence, must be surrendered of
course.

If we rightly understand the professor, in his attempt

48 PRELIMINARY DISCOURSE.

to explain himself, the following is a brief of his reason-
ing on this subject.

I. All diseases consist in morbid excitement.

II. Morbid excitement is an unit,* because it is the
product of stimuli or irritants acting on excitability.

III. Therefore all diseases are an unit.

Such we believe to be the syllogistic structure on
which alone rests the doctrine of the unity of disease.

When correctly analyzed, this form of argument will
be itself found to consist of two fundamental and distinct
assumptions — the unity oj excitabiliti, — and the unity of
stimuli. These assumptions are fairly and necessarily
implied in the middle proposition of the syllogism.

If it be true, that excitability is, in every part cf the
body, and under all circumstances, the same, and that all
stimulants capable of acting on it are also the same, it
follows, of necessity, that the result of this action can be,
in no case, dissimilar — Disease must, then, be an unit,
differing from itself, under different circumstances, in no
other respect than that of its force. These two assumed
propositions it shall now be our business to analyze and
examine.

From facts and reasonings which were submitted to
the consideration of the reader, in a preceding part of
this discourse, it is contrary to the fundamental princi-
ples of our nature, that excitability should be, in all parts
of our systems, the same. The hypothesis is one of the
offensive crudities of the Brunonian doctrine, and ap-

* The Brunonian doctrine on the subject of excitement, embracing, as it
does, the unity of that property, is inconceivably absurd. It amounts to an
extravagance of folly, which almost surpasses the limits of belief. Accord-
ing to this sectarian doctrine, life consists in excitement, health in excite-
ment, and disease, in excitement. Yet excitement is an unit : therefore life,
health, and disease are the same. This is no misrepresentation, nor even
exaggeration of the doctrine: it is the doctrine expounded precisely as it is
maintained.

PRELIMINARY DISCOURSE. 49

pears to be utterly repugnant to all that we know of
physiological truth.

Although we do not believe that excitability derives
its existence from the mere organization of matter — for
it is a quality of matter not organized — we feel, notwith-
standing, confident, that it is greatly modified by it. So
also is the capability of action — we mean the capability
of a part to assume any particular form or mode of ac-
tion. These facts are of primary importance in the
present discussion.

Were excitability the same in every part of the body,
it would, in each, be acted on by the same stimulants,
and in the same way. The fact, however, is otherwise.
Light, a powerful stimulus to the eye, and indirectly to
certain other parts, produces no excitement in the organ
of hearing; nor does air on the organ of vision. Augment
their force to any degree that is practicable, the result is
still the same. Air and light, therefore, differ as stimuli,
or the eye and ear differ in their excitability. In either
case the argument is in our favour: for, to prove the
unity of disease, the unity of stimuli as well as that of
excitability must be conclusively established.

Nothing will act on the olfactory nerves but odours,
nor on the nerves of taste but sapid bodies. Here again
is something specific in relation either to excitability or
stimuli. If there were not a radical difference in the
excitability of these two sets of nerves, the same stimu-
lants would act, and act alike, on them both. If there
were not something specific in the nature of odours,
they would not be alone capable of awakening the sense
of smell; nor would sapid bodies be alone capable of
exciting taste, unless they were different in their na-
ture from other stimulants. Heat, cold, and all other
stimulating agents produce sensation in the tongue and
nares; but not the sensation of taste or smell. These

vol. 1. g

50 PRELIMINARY DISCOURSE.

two latter sensations, therefore, can be nothing else than
the result of specific stimuli acting on specific excita-
bility. With equal correctness might similar obser-
vations be made in relation to the nerves of touch.

The organs of the five external senses, then, exhibit
so many unequivocal examples of specific excitability.
They, in this respect, differ from each other and from
the rest of the system, as essentially and palpably, as
silicious differs from argillaceous earth, an oak from an
elm, or a bear from a buffaloe.

The excitability of the stomach is very strikingly,
and we believe, specifically, different from that of the
lungs, the intestines, the lacfceals, and the blood-vessels.

Many purgatives and other articles which pass through
the stomach, if not entirely unfelt, at least, without much
inconvenience, produce in the bowels the utmost dis-
order. Bile the stimulus of which is necessary to the
healthy and efficient action of the intestines, cannot be
received into the stomach without giving rise to nausea
and vomiting.

Carbonic acid gas, which is to the stomach a grateful
and salutary stimulus, proves immediately fatal when
applied to the lungs. This can be attributed to no other
source than a difference in the excitability of the two
organs.

Such is the peculiar excitability of the lacteals, that
they reject at once the undigested alimentary matter,
which is received without reluctance or injury by the
stomach and intestines.

The blood appears to be the only stimulus that can
be at all tolerated by the internal surface of the heart,
arteries and veins: every other substance brought into
contact with that extremely delicate portion of our sys-
tem produces convulsions and sudden death. But if a
portion of blood be received in a crude state into the

PRELIMINARY DISCOURSE. 5\

stomach, it rarely fails to prove the cause of sickness,
and perhaps vomiting. The existence of different spe-
cies of excitability can alone explain these phenomena.

The lips, the organs of generation, and the female
breasts, manifest, also by incontestable evidence, the
existence of specific excitability. They are each capa-
ble of being acted on by stimuli that do not at all affect
the others.

Were we to embrace in this analysis the whole of the
human body, and give a complete history of the excita-
bility of every particular part of it, our work would
consist of little else than a record of differences. No
two portions of the body that are differently organized
would be found to be alike in their excitability. Nor
does it appear possible that the case can be otherwise.
We should as soon expect parts differently organized
to be similar in their functions as in their excitability —
as soon expect the skin to act like the glands, the
glands like the muscles, the muscles like the nerves,
the nerves like the blood-vessels, and the blood-vessels
like the absorbents, as the whole or any two of these
parts to be similar in their excitability.

It is evident, then, that one of the assumptions, on
which rests the doctrine of the unity of disease, viz. the
unity of excitability, is utterly unfounded. We shall
proceed to a brief examination of the other, viz. the
unity of stumuli.

Of the essence of stimuli we know nothing. We can
judge of them only by their external qualities, their
properties, and their effects. If they be alike in these,
we must consider them alike in their nature; and if dis-
similar in these, dissimilar in their nature. From this
rule of inference it would be unphilosophical to depart.
Let it be applied to the solution of the present question.

In the properties of weight and hardness, elasticity

j2 PRELIMINARY DISCOURSE.

and cohesion; and in the external qualities of figure and
colour, smell and taste, no two stimulants are precisely
alike. In these respects, opium, alkohol, and ether are
unlike wine, volatile alkali, and Peruvian bark ; prepa-
rations of mercury unlike preparations of steel; Glau-
ber's salts and castor oil unlike senna and rhubarb:
asafoetida and musk unlike castor and camphor ; and
cantharides and spirits of turpentine unlike every other
substance with which we are acquainted. The same
thing is true with respect to all stimulating substances,
of which we have any knowledge, and the properties
and external qualities of which we are capable of exa-
mining. No two of them are precisely alike. Consider-
ed in their resemblance to each other, therefore, they ex-
hibit none of the characters of unity.

If we examine them with a view to their operation on
living matter, the isaue will be found in an equal degree
unfavourable to the hypothesis we are opposing. When
applied to the human body, whether in a diseased or a
healthy condition, they are far from being marked with
an identity of effect. On the other hand, out of the
whole catalogue, no two can be selected that act pre-
cisely in the same way. Although they all timulate, yet
each one acts witli some modifications peculiar to itself.
Of this fact no physician of experience can be ignorant.
Opium and its several preparations stimulat ; but, in
doing this, they relieve pain in a manner superior to all
other remedies, and also in a different mode. It is in
vain to assert, with Brown and his followers, that they
differ from wine, aikohol. and ether, only in being more
powerful and diffusible in their effects. The assertion
is contrary to universal experience. Opium is daily
exhibited, with great advantage, in cases of topical in-
flammation, and other diseases, wherein wine, ardent
spirits, aromatics, and all kinds of stimulating aliment

PRELIMINARY DISCOURSE. 53

and drink would be injurious. In relation to its effects
on living matter, opium is a substance sui generis. If
certain articles of materia medica resemble it, in some
respects, in their mode of action, they differ from it
widely and essentially in others.

Mercury stimulates: but, in its action on the salivary
glands, it is altogether unique. The stories we hear, of
a like salivation being produced by other substances,
are either unfounded, or the effect is to be attributed to
some peculiarity in the systems of those in whose cases
it has occurred. The event cannot be regarded in the
light of a general and settled principle. Although
many articles, when chewed, produce a temporary dis-
charge of saliva, mercury is the only permanent sialo-
gogue.

A further and very striking example of the specific
operation of stimuli is furnished by cantharides. Other
articles, when applied to the skin, produce vessication:
but it may be confidently asserted, that, in its entire
operation, no one exactly resembles this. It is a medi-
cinal substance specific in its character.

The history of the external senses furnishes exam-
ples, conclusive in themselves, of the diversity of stimu-
lants. Were the doctrine of the identity of these
agents true, the different colours which objects present
to the eye, would be wholly inexplicable. No one will
contend, that, by any modification in its force, a blue
ray of light Can be made to produce on the optic nerve
the sensation of redness, a red ray that of orange, or an
orange ray that of yellowness. Each of these sensa-
tions, as well as those of the remaining colours, can
arise only from the specific peculiarity of the stimuli
that produce them.

Similar observations may be made in relation to the
operations and functions of the tongue. The leading

54 PRELIMINARY DISCOURSE.

tastes of sweet, sour and bitter, with all the numerous
intermediate sensations, give testimony, which nothing
can resist, of the diversity of stimulants. An identity
of impression can never produce them.

Nor are the innumerable and peculiar diversities of
odours and sounds less pointedly in favour of the doc-
trine we are defending. The different kinds of organic
action on which they depend, can arise only from a cor-
responding difference in the stimulating agents by which
they are excited.

Certain stimulating substances are, in their effects,
not only different, but in direct opposition to each other.
Rhubarb, aloes and gamboge stimulate and purge; sac-
charum saturni, opium, and Peruvian bark, stimulate
also, but produce costiveness. Tartarized antimony,
ipecacuanha and vitiiolated zinc, stimulate and excite
vomiting; seltzer water, an infusion of mint, and a mix-
ture of brandy and water also stimulate, but check vo-
miting. Squills and digitalis stimulate and give rise to
an increased secretion of urine; opium, cicuta, hyoscy-
amus, and perhaps the whole family of the narcotics,
stimulate in like manner, but diminish the secretion of
urine.

Certain cordial articles, as wine, brandy, and savory
food, when received into the stomach of a person weak-
ened by hunger, stimulate its coats and produce an im-
mediate augmentation of strength; but arsenic, crystal-
ized muriate of mercury, and the juice of tobacco,
stimulate also in a very high degree; yet, when taken into
the stomach, they diminish strength. This difference
in result must be owing to the different modes of action
of the substances employed. The former class consists
of salutary stimuli, which, when skilfully administered,
always give vigour; the latter of deleterious ones, which,
when swallowed in sufficient doses, never fail to take it
away.

PRELIMINARY DISCOURSE. 55

There is yet another source of diversity in the opera-
tion of stimuli, to which we have not heretofore suffi-
ciently adverted It is their peculiar fitness for acting,
some on one, and some on another, of the subdivisions
of the body. An attempt has been made even to class
the articles of the materia medica on this principle.
Opium acts chiefly on the brain and nerves; mercury
on the glands and lymphatics; wine and aromatics on
the heart and blood-vessels; preparations of steel on the
stomach; and squills, digitalis, and uva ursi on the kid-
neys.

On what but a conviction of their diversities, do wri-
ters on materia medica found their division and classi-
fication of stimulants? — representing them to consist of
astringents and tonics, corrosives and antispasmodics,
errhines and sialagogues, expectorants and emetics,
cathartics and diuretics, diaphoretics and emmena-
gogues, and some others? Were all these articles the
same, such a classification would be nothing but a tis-
sue of systematized error, disingenuous in its nature
and delusive in its effects. Yet, singular and inconsis-
tent as it may appear, it was adopted by Dr. Rush in
his lectures on therapeutics. Hence, in a practical
point of view, that teacher supported the doctrine of
the diversity of stimulants, although, theoretically, as an
unitarian in pathology, he was an advocate for their
identity. Against his favourite hypothesis, therefore,
he leaves us the weight of his own authority.

There evidently exists, then, a two-fold ground of
difference in relation to the result of the operation of
stimuli; a difference in the qualities of the articles them-
selves; and a difference in the susceptibility and struc-
ture of the parts on which they are peculiarly fitted to
act. These grounds are, each in itself, unfriendly to the

56 PRELIMINARY DISCOURSE.

doctrine of the unity of disease, and, when united,
necessarily fatal to it.

From what we know of Nature, we are bound to be-
lieve that she does nothing in vain. But, were all
stimuli the same, where would be the use of such an
extended catalogue of thorn as she has offered to our
selection? Why should they superabound in the animal,
vegetable, and mineral kingdoms? In a medical point of
view, at least, this profusion would be superfluous, and
even embarrassing. With one of them, as well as with
the whole, might the physician fulfil every possible indi-
cation of cure. Let him take, for example, common
brandy, and, by dextrously varying the strength and
dose of it, his business would be done. With this article
alone he might purge or sweat, puke or salivate, pro-
mote absorption or increase the action of the kidneys
and other glands, according as the one or the other of
these processes might be necessary. He might ev(m,
as would at times be requisite, effectuate several indica-
tions at once.

A view of things more perverted by error, or more
replete with absurdity than this, can scarcely be i;
gined. Yet is it a correct picture of the issue to which
the doctrine of the unity of stimulants necessarily lea-Js.

Seeing, then, excitability is diversified, and stimulus
diversified, and the several subdivisions and organs of
the body incapable of acting alike, in consequence of
the entire diversity of their structure, there exists in
nature no shadow of foundation for the doctrine of the
unity of disease.

Thus far we have ventured to proceed, conducted by
analysis, and directed on our way by the light of first
principles. There remains to be considered another
source of argument, more fatal, perhaps, to the hypo-

PRELIMINARY DISCOURSE. 57

thesis we are combating, than any to which we have yet
Jia ; recourse, ft is the doctrine of specific poisons.

With this doctrine before him, and possessing, as we
think lie did, a perfect knowledge of it, it is somewhat
more than singular — it is truly astonishing, that Dr.
Rush should ever have contended for the unity of dis-
ease — that he should have pronounced small pox and
chicken pox. kine pox and lues venerea, measles and
hoopmg-cough, the itch and the leprosy, to be the same
malad* !

Was it not perfectly known to Dr. Rush, and is it
not as well known at present, to his followers — if, in
relation to tiiis point, he has any followers — that, with
as much certainty as a grain of wheat produces a stalk
of wheat, or a grain of oats a stalk of oats does the
poison of small pox produce small pox and nothing else?
the poison of kine pox. kine pox and nothing else? —
and, that neither of these diseases can be brought into
existence by the poison of lues venerea, the leprosy, or
the itch? But causes are known by their effects; and
different effects uniformly occurring under similar cir-
cumstances, arise, of necessity, from different causes.

Is it not a fact of universal notoriety, that persons who
have been once affected by small pox, are not liable to
it again, although their liability to other diseases re-
mains unaltered? and does not this fact evince, by a
force of evidence which nothing can resist, that small
pox is different from every other complaint? If it were
not different, why should the system be exempt from it
alone, its susceptibility as to other maladies remaining
unchanged? Were it like bilious fever, pleurisy, or
rheumatism, wherefore should the s) stem, having once
experienced it, be secure from it and liable to them.

We shall illustrate this point by a familiar example.
Twenty-four kinds of seeds uniformly take root and
vol. 1. h

58 PRELIMINARY DISCOURSE.

flourish in a certain soil. A twenty-fifth refuses to
quicken in the same soil, but vegetates freely in every
other, producing a plant that bears no resemblance to
any one of the twenty-four. Is not the last seed speci-
fically different from all the others? So plain a question
admits of but one reply.— Were there no objections to
the unity of disease but those which small pox furnishes,
they alone would subvert the doctrine.

Again: — Disease consists in morbid action. If, there-
fore, disease be an unit, morbid action must be also an
unit. But the several morbific poisons — those, for ex-
ample, of small pox, kine pox, and lues venerea, which
have been already shown to be different from each other,
because they give rise to different effects — are the pro-
ducts of morbid action. Either, therefore, different
products result from the same diseased action, or the
diseased action which gives origin to these products is
different. But the former branch of the proposition is
unreasonable: the latter must be, therefore, admitted as
correct.

As well might we expect the same kind of generative
action, in the animal kingdom, to be productive of an
elephant and a hippopotamus, and in the vegetable, of
an oak and a cedar, as the same morbid action which
produces the poison of small pox, to be productive also
of that of lues venerea.

It must be regarded in the light of an axiom in pa-
thology, that there are as many kinds of morbid action —
in other words, of disease — as there are of morbific
poisons resulting from it; each poison being the pro-
duct of a corresponding specific secretory process. As,
in health, the same kind of action which secretes bile
from the blood, cannot secrete saliva, nor that which
secretes urine secrete also the semen masculinum;
neither is it possible for that morbid action which se-

PRELIMINARY DISCOURSE. 59

cretes from the blood the matter of small pox, to secrete
also that of lues venerea: nor that which forms the
poison of kine pox, to generate also the poison of
leprosy.

With all these truths — for so they must be called—
arrayed against the hypothesis, it is to us, we repeat, a
subject of astonishment, that Dr. Rush, or any of his fol-
lowers, should have seriously contended for the unity of
disease. The error appears to be as gross and gigantic,
as any that is recorded in the annals of medicine. It is
scarcely inferior to that fanatic delusion, which, in the
days of Paracelsus, derived the contagion of pestilence
from the moon. That it attracted proselytes at first, is
sufficiently extraordinary: that it should retain them
now, we think impossible.

Against the hypothesis of the unity of disease, Dr.
Rush has himself, we think, in sundry instances, fur-
nished us with stronger and more conclusive arguments,
than any other physician whose opinions are on record.

In addition to the pulse of health, there are, as he
assures us, twenty diseased pulses, each one of which is
capable of being distinguished from all the others.

Rut a pulse is nothing else than a state of action in an
arterial tube — a diseased pulse being of course a dis-
eased state of action. In Dr. Rush's opinion, then, the
same artery is capable of manifesting twenty-one differ-
ent kinds of action, of which twenty are morbid.

Is this true of a single artery, and can it be, at the
same time, true of the whole system, that, complex and
varied as it is in its structure, it, as a compound, is ca-
pable of taking on and exhibiting but one kind of ac-
t on? — that a very simple and subordinate part of the
machine can manifest, in its action, the variety of
twenty; and yet, that the entire machine, consisting

60 PRELIMINARY DISCOURSE.

of at least twenty different parts, is capable, in its ac-
tion, of nothing but impy?

Unequal as we ourselves are to the difficulty of the
task, it is to the followers of Dr. Rush that we are autho-
rized to look for a solution, of this paradox. If they can
make it appear, that both positions of their leader are
true, \iz. that a single artery can exhibit twenty kinds
of action, and the whole system but one, then, indeed,
is the human body, in tlte language of the poet, and, in
the true sense of the terms, the " riddle of the world !"

Thus far have we endeavoured to show, on d- ctrinai
grounds, the /(diary of the hypothesis of the unity of
disease. It is our duty to add, that, in a practical point
of mew, it is < minently danga'tnis.

On the accuracy and perfection of the discrimina-
tion of diseases, rest entirely the safely and success of
the practice of physic. We must, therefore, be permit-
ted to add, that that physician who would venture to
treat *all diseases as if they were the same, would be
unworthy to be intrusted with the care of any. His
practice would itself prove a source of mischief as
fruitful as the complaints he might be called to attend.

Such a practitioner enters the room of a patient, la-
bouring under apoplex) or gout in the stomach, inflam-
matory rheumatism or bilious colic. Misled by the de-
lusive notion of the unity of disease, he pronounces
the complaint to be the same as intermitting fever or
lues venerea, and attempts its removal by bark and
wine, or the exhibition of mercury. The issue of his
practice we need not mention. If it be not death, the
siek man will be indebted for his escape, not to the
skill of his physician, but to the strength of his own
constitution, or the kindness of heaven.

In a word, that physician who firmly believes in the

PRELIMINARY DISCOURSE. $J

unity of disease, and perse veringly practises in confor-
mity to his belief, can scarcely fail to be in the daily
violation of that divine precept, which forbids our be-
ing instrumental in the taking away of human life.

Having thus, as we conceive, by demonstrating the
fallacy of the unity of disease, demolished the strong-
hold of the professor's argument against classical noso-
logy, it would be superfluous to pursue him through
the details of his opposition. When the citadel has
fallen, the outworks must be surrendered as a matter
of course.

We had designed, after closing this discussion, to
enter on a critical examination of the merits and de-
fects of the several s) stems of methodical nosolog} that
are now extant. But the protraction of our discourse
considerably beyond the limits we had assigned to it,
compels us, for the present, to relinquish our intention.

We shall, therefore, content ourselves with briefly
observing, that, in the main, we consider the system of
Di. Cullen as entitled to a preference over all others.
W e think it more correct in its principles, more com-
prehensive in its outline, more perspicuous in its ar-
rangement, and much more simple and natural in its
details. To aid in restoring to medical science in the
United States, by means of that system, somewhat of
the classical character, which, through the writings and
teachings of Dr. Rush, it has been rapidly losing, con-
stitutes w ith us a leading object in becoming the editor
and commentator of the present work.

But valuable as the nosological system of Dr. Cullen
is, its faults are numerous, and several of them conspi-
cuous. Were we to pass them unnoticed, we should
be unfaithful to our duty. A brief consideration, there-
fore, of some of the most important of them shall close
our discourse.

62 PRELIMINARY DISCOURSE.

Were it our purpose to be rigid and fastidious in
our critical remarks, we should not pass without con-
demning, what we consider as an error in Dr. Cullen's
definition of the first Order of his class Pyrexia. The
classical pathologist will recollect that it is the order
Febres, to which we allude. The following is the Pro-
fessor's definition of it.

" Proegressis languore, lassitudine, et aliis debilitatis
signis, pyrexia sine morbo locali primario"

The clause in this definition, which, strictly speak-
ing, we think objectionable, is that printed in Italics.
Although the Febres of Dr. Cullen exhibit no topical
affection so strongly marked, as his Phlegmasia? do, it
is, notwithstanding, incorrect to represent them as en-
tirely destitute of such a character. All fevers are, at
Jirst, nothing more than topical affections. They be-
gin at a point, that point being the spot first injured by
the morbific cause, and extend by sympathy, until they
occupy the whole system. They are truly, as Dr. Dar-
win represents them, diseases of association. An idio-
pathic fever, in the sense in which it is usually under-
stood, is, strictly speaking, a creature of the fancy. It
has no more an existence among the works of nature,
than a Polypheme or a Chimasra, a Harpy or a Ca-
liban.

Fevers may be compared to vegetables, the spot ori-
ginally attacked being the root, on which the stem and
branches depend for sustenance. Destroy or remove
the root, the stem and branches necessarily wither. In
cases of fever, heal, in an early stage, the first injury,
which is the cause of all that follow* and its effects
will disappear. It would seem U be essential, there-
fore, to the existence of the complaint, that, for a time,
at least, the part originally injured should retain the
character of a topical affection. This radix, or point

PRELIMINARY DISCOURSE. 6S

of beginning, is, to the general disease, the " morbus
localis primarius."

It is true that this primary local affection does not,
under the order Febres, show itself in the form of real
pain. It does not on that account, however, the less
certainly exist; although, to common apprehension, it
may be the more difficult to prove its existence. It is
an irritative, not a sensative affection, and has, as we
believe, its seat in the stomach. Hence arises the dif-
ficulty of proving it to be a reality.

We have, however, in sundry instances, conclusive
evidence of the existence of such an affection, and,
therefore, very strong ground to infer its existence in
cases where it is not so palpable to sense.

In the kine pox and the inoculated small pox, the
affection of the arm is purely irritative. It produces
no pain. Were it situated on some internal part, re-
mote from sight — the stomach, for example — we should
have no evidence, except its effects, to convince us of
its existence. Yet does it possess a sufficiency of force
to excite in the system a general commotion — to pro-
duce a fever on principles of sympathy.

The same thing may be said in relation to the topical
injury in cases of tetanus, arising from a punctured
wound. The affection is altogether irritative. Being
unaccompanied with pain, it is oftentimes forgotten
even by the patient himself, before the general disease
makes its appearance. Were it an internal affection
its existence would never be suspected.

Hydrophobia, from the bite of a rabid animal, affords
another example of an affection entirely irritative. The
wound heals, gives no pain, and is forgotten. But a
secret irritation lingers in the spot, which, in a short
period, produces, by sympathy, a fatal malady.

In the diseases of children arising from dentition, in
epilepsy, and many other complaints which we cannot

64 PRELIMINARY DISCOURSE.

now enumerate, the local affection is, in like manner,
irritative. It excites no pain or strong sensation, to
give notice of its presence Yet would it be errone-
ous to apply to these diseases, the terms "sin mo.oo
locali primario."

Although the fact is not necessarily con ecte 1 h
the present discussion, we shall, never heless, observe,
that a mere irritative local affection is not only a reality,
but more formidable, perhaps, as a source of general
disease, than an affection which is sensative.

Another ground of argument against the correctness
of Dr. Cullen's definition is, that all febrile affections
which we are capable of clearly tracing to their com-
mencement, most certainly originate in a topical affec-
tion.

Thus, some arise from wounds, and are termed
symptomatic; others from severe blows, sprains, or the
fractures of bones, all of which are in their nature local;
others from a debauch, or from improper articles of ali-
ment, which excite a local affection of the stomach;
others from the swallowing of poison, which evidently
operates in the same way; and others, again, from a long
continued exposure of a part of the body to dampness
or cold. In this latter case, as in all the former, the
part exposed being first affected with a local complaint,
disorders the system through the medium of sympathy.

It is impossible for any febrile cause, with which we
are acquainted, to gain access to the whole system at
once. It must first, therefore, attack locally, and after-
wards extend its ravages on sympathetic principles.

Such are our reasons, in part, for excepting to Dr.
Cullen's definition of his order Febres. Although, in
these diseases, the primary local affection does not very
strongly manifest itself, we feel, notwithstanding, a con-
viction that it exists. It is obvious to our reason, al-
though not to our senses. Wrong, therefore, as it

PRELIMINARY DISCOURSE. 65

might, perhaps, have been for Dr. Cullen to have em-
braced it in his definition, we deem a denial of its exist-
ence much more exceptionable. A qualified admission
of it would have been most consistent with the princi-
ples of correct pathology. The order might have been
characterized in the following terms:

Proegressis languore, lassitudine, et aliis debilitatis
sign is, pyrexia sine morbo locali primario maxime
evidente.

We think Dr. Cullen wrong in representing conta-
gion as an essential characteristic of the Typhus and Sy-
nochus fevers. The contagious nature of these dis-
eases, in the United States, is extremely questionable.
We are inclined to believe that the general amount
of medical testimony, as derived from experience and
observation, is against it. Our own opinion, delibe-
rately formed from these sources, is unfavourable to the
doctrine.

By contagion we mean a specific poison — for if it be
not specific it is not contagion, in as much as it is inca-
pable of self-propagation — generated in the animal sys-
tem by morbid action. In other words, we understand
by it, a secreted morbific matter, the offspring of a pecu-
liar diseased action, and capable of exciting action pre-
cisely similar, which will again produce a poison of the
same kind. From such a matter we have no reason to
believe that Typhus and Synochus fevers arise. We
are much more inclined to regard them as the offspring
of a poison resulting from putrefaction. In the Uniled
States, cleanliness and free ventilation prevent them
from spreading. But such measures will not prevent
the spreading of diseases that are truly contagious.
Their insufficiency to arrest the progress of small pox
is known to every one who is acquainted with the sub-
ject.

VOL. I. I

66 PRELIMINARY DISCOURSE.

Under the genus Typhus, our author places the yel-
low fever of the West Indies and the United States. In
this he is mistaken. Yellow fever is a species or variety
of bilious fever, not of typhus. We do not believe the
yellow fever of the United States to be a contagious dis-
ease, in as much as it will not spread beyond the limits
of a vitiated atmosphere. As there exists in yellow
fever an inflammation of the stomach, it belongs, per-
haps, of right, to the order Phlegmasia?.

As our nosologist appears to be himself sensible of
his error in referring Hectic fever to the order Febres,
sine morbo locali primario, it would be superfluous in
us to dwell on that point. A local affection forms as
essential a part of hectic fever, as it does of ophthalmia
or hepatitis. The disease, therefore, belongs to the or-
der Phlegmasia^.

Under the order Exanthemata, Dr. Cullen includes
several diseases, which, in their characters, do not cor-
respond with his general definition. He represents this
order to consist of " Morbi contagiosi, semel tantum in
decursu vitee aliquem afficientes." Comprised under it
we find, Erysipelas, Miliaria, Urticaria, Pemphigus,
and Aptha, neither of which is ever known to be com-
municated by contagion. But the error into which the
professor has fallen does not terminate here. Of erysi-
pelas and urticaria certainly, and, we believe of pem-
phigus also, the same individual is liable to repeated
attacks. Instances are not wanting in which erysipelas
is even remarkable for the frequency of its recurrence.
Pestis, or true plague, respecting the contagious na-
ture ofw r hich we shall speak hereafter, does not belong
to the order Exanthemata. Its whole history convinces
us that its proper place is under that of Febres — or,
perhaps, of Phlegmasia. Its most natural and striking
affinities are to typhus, or malignant bilious fever.

PRELIMINARY DISCOURSE. 67

There exists strong presumptive evidence that it is the
same disease with the yellow fever of the United States,
modified by climate, and, perhaps, other causes.

Under the order Hemorrhagiae, Dr. Cullen places
Phthisis Pulmonalis.

This arrangement is injudicious. Haemoptysis is only
an accidental symptom of pulmonary consumption. The
complaint, consisting of fever connected with an inflam-
matory topical affection, belongs, of right, to the order
Phlegmasiae.

From the manner in which Dr. Cullen has filled it
up, the order Proflnvia ought to be abolished.

He has included under it but two genera, catarrh and
dysentery. Every symptom and character of these dis-
eases declare them to belong to the order Phlegmasiae.
Like phthisis pulmonalis, they consist of fever and a
topical affection, which is always inflammatory. Their
affinity to the Phlegmasiae are, therefore, natural and
strong.

If the order Profluvia be retained at all, with much
more propriety might it be made to include, diarrhoea,
diabetes, fluor albus, and, perhaps, pyrosis. Although
these complaints consist also, in part, of a topical affec-
tion, it is not always of an inflammatory character.

The definition bestowed by Dr. Cullen on his class
Neuroses, appears to be, in no small degree, faulty, in
representing the diseases which it embraces as being
"sine morbo locali" free from any topical affection.

Apoplexy and palsy are its two only genera, in both
of which there exists a local disease — of the stomach,
perhaps, in the first instance, and of the brain, by
sympathy. It is to relieve the latter that we bleed,
and the former that we purge so copiously in this com-
plaint.

Our author has committed another error in consider-

68 PRELIMINARY DISCOURSE.

ing hydrocephalus internus as a species of apoplexy.
According to his own definition of it, it evidently be-
longs to the order Phlegmasiae. The affection of the
head is inflammatory, and the disease is marked, in its
early stage, always with considerable, and sometimes
with violent fever.

The disease of hydrophobia has been very rarely an
object of our attention. We have seen enough of it,
however, to be convinced, that it is not essentially a
spasmodic affection. Even Dr. CuhWs own definition
leads us, of necessity, to this conclusion. The spasm is
nothing but an accidental symptom, although its occur-
rence in the disease must be acknowledged to be very
frequent.

When we take into consideration the entire history of
hydrophobia, we have no hesitation in referring it to
the class Pyrexia; for it is certainly marked by febrile
heat. Of this class it has, perhaps, the strongest affi-
nity to the order Phlegmasia?.

To the class Pyrexia, and order Phlegmasiae, ought
the tabes purulenta of Dr. Cullen to be referred, instead
of being placed, as it is by that writer, under the class
Cachexias, and order Marcores. It consists in a topical
inflammatory affection accompanying a fever.

Under the class Cachexias and order Intumescen-
tias, has our author thought proper to arrange hydro-
thorax.

In this again he does not appear to be altogether
eorrect. Hydrothorax, oftentimes, at least, if not ge-
nerally, commences as an inflammatory affection. It
is one of the modes of termination of long continued
peripneumony, asthma, catarrh, and other inflamma-
tory complaints of the thorax, when they frequently
occur. It is, in fact, the result of chronic inliamnia-

PRELIMINARY DISCOURSE. $9

tion. We are inclined to believe that its most natural
affinities are to the diseases belonging to the order
Phlegmasise.

As Dr. Cullen's " First Lines of the Practice of Phy-
sic" do not embrace his class Locales, the last in his
system of Methodical Nosology, we shall decline, for
the present, making any remarks on that extensive fa-
mily of diseases.

TABULAR VIEW

OF

CULLEN'S SYNOPSIS.

AS we think it highly important for young gentle-
men to be accustomed, from the commencement of
their medical studies, to look at diseases through the
medium of system; and as this can be done with most
facility and advantage, when the view is exhibited in
a compressed form, and fairly addressed to the sense of
vision ; we have resolved to lay before our readers a
tabular representation of Cullen's Synopsis of Methodi-
cal Nosology, exhibiting diseases systematically ar-
ranged into classes, orders, and genera; with an ex-
planation of the terms, and the original words from
which they are derived.

CLASS I.

PYREXIA, {Febrile Diseases) from srvp, fire, and ff<s, a habit.

ORDER I.*
Febres — Fevers.

section I.

Intermittentes (Intermittents.)
Genus 1. Tertiana ( Tertian).

2. Quartana {Quartan).

3. Quotidiana ( Quotidian).

[* We think Dr. Cullen mistaken in representing this order of
diseases as exempt 1'roin any primary topical affection.— j£rf.]

72 TABULAR VIEW,

SECTION II.

Continuae (Continued).
Genus 4. Synocha, (Simfile Inflammatory Fever) from a-v\)£%v, to
z continue.
5. Typhus, (Nervous Fever) from rupej, stupor.f

Mitior, (Mild).\

. — Gravior, (Malignant).^

i Icterodes, ( Yellow Fever) from iKre^og, jaun-

dice, t
[t These diseases are not contagious. The last should be
under the order Phlegmasiae. — Ed.~]
Genus 6. Synochus, from (rwex,u, to continue.

Hectica, (Hectic Fever) — [This should stand under
the order Phlegmasiae. — Ed.'}

ORDER II.

Phlegmasia, (Inflammations) from <p*.eyv, to burn.
Genus 7. Phlogosis, ( Phlegmonous Inflammation).

Apostema, (Abscess) from *#•<>, from, and ttrre^i, to

stand.
Gangraena, (Gangrene,) from yccyygcciv*, from ygxa, to

eat up, or consume.
Sphacelus, from <r<pot.x.etos, from c-0«tt«, to kill.

8. Ophthalmia, (Inflammation of the Eye) from o$6uXim<;.

9. Phrenitis, (Inflammation of the Brain) from (ppentrn, a

frenzy.

10. Cynanche, (Inflammation of the Throat) from xtwv, a

dog, and «v^«, to strangle.

. Tonsillaris, (of the Tonsils).

Maligna, (Malignant).

' Trachealis, (Crou/i).

Pharyngaea, (of the Pharynx) from <pupwy%,

the upper part of the oesophagus.

11. Pneumonia, (Inflammation of the Thorax) from wiv/mii,

the lungs.
. Peripneumony, from nigi and mtv^m.

Notha, (Bastard Perifineumony).

Pleuritis,(.P/ezm'si/)from nXevpx, the mem-
brane lining the lungs.

■ Vomica (Abscess of the Lungs).
————— Empyema, (Internal Abscess) from a,
•within, and wnav, pus.

TABULAR VIEW. 73

Genus 12. Carditis, {Inflammation of the Heart) from x.*ehct, the
heart.

13. Peritonitis, (Inflammation of the Peritoneum) from

zrsgiravuov, from ■sn^'.rtitu^ to stretch around.

14. Gastritis, (Inflammation of the Stomach) from yxrvp,

the stomach.

15. Enteritis, (Inflammation of the Intestines) from evregov,

an intestine.

16. Hepatitis, (Inflammation of the Liver) from «j5r«f, the

liver.

Acuta, (Acute).

Chronica, (Chronic).

17. Splenitis, (Inflammation of the Sfileen) from s-ttAjjv, the

spleen.

18. Nephritis, (Inflammation of the Kidneys) from H0pt>s,

the kidney.

19. Cystitis, (Inflammation of the Bladder) from *.v(ms,

the bladder.

20. Hysteritis, (Inflammation of the Uterus) from vo-regcc,

the uterus.

21. Rheumatismus, (Rheumatism) from fcvfixri^u, to be

affected with defluctions.
■ Acutus, (Acute).

— — — — — — Arthrodynia, (Chronic Rheumatism)

from «f 0f«v, a joint, and o^v^, pain.

22. Odontalgia, ( Tooth-ach) or rather pain in the jaw from

a carious tooth — from eJW«, a tooth, and «Ayes, pain.

23. Podagra, (Gout) from ws?, the foot, and «yf#, a sei-

zure.

' Regular.

■ Atonic.

Retroceding.

Wandering.

24. Arthropuosis, (Abscess in a Joint) from utfgov, a joint,

and mov, pus.

ORDER III.

Exanthemata, (Erufitive Diseases) from *f and <*v0es, a flower.
Genus 25. Variola, (Small Pox).

— — — Discreta, (Distinct) a mild disease.

' Confluens (Confluent) a malignant disease.
VOL. I. K

74 TABULAR VIEW.

Genus 25. Variola Variolae Vaccinae, (Kine Pox) from vacca, a
cow.
[This disease was not known to Dr. Cullen. — Ed.]

26. Varicella {Chicken Pox) the diminutive of variola.

27. Rubeola (Measles) from rubeo, to become red.

28. Scarlatina, (Scarlet Fever).

29. Pesus, (Plague),— [This belongs to the order Febres

or Phlegmasiae. — Ed.]

30. Erysipelas, (An Inflammation of the Skin).

31. Miliaria, (Miliary Fever) so called from the cuticular

eruptions resembling millet seed.
32 Urticaria, (Nettle Rash) from urtica, a nettle.

33. Pemphigus, (a Pustular Eruption) from nt /*■?!& a

pustule.

34. Aphtha, (the Thrush) from ct*r6cci. [Most of the dis-

eases of this order are not contagious — Ed.]

ORDER IV.
Hemorrhagic, (S/iontaneous Effusions of Blood) from «<jwf-
. £<*>£*>, to discharge blood — from eci^ec, blood, and
pta>, to flow.
Genus 35. Epistaxis, (Hemorrhagy from the Nose) from esnra^w,
to drop from.

36. Haemoptysis, (S/iitting of Blood) from «<f«t, blood,

and w?tw, to spit.

37. Phthisis, (Consum/ition) from $0<ff-<c, from QBea, to cor-

rupt. [This belongs of right to the order Phleg-
masiae. — Ed.]

38. H3emorrhois,(P?7es) from *«/»«, blood, and />'«», to flow.

39. Menorrhagia, (An Excessive Flux of the Menses) from

(xkvix, the menses, and pyyvvKpi, to break out.
Haematemasis, ( Vomiting of Blood) from «//*«, blood,
and ifJLtu, to vomit.

ORDER V.

Profluvia, (Fluxes, with Fever) from firofluo, to overflow.
Genus 40. Catarrhus (Catarrh) from Kxrctpfeu, to flow down.

41. Dysenteria, (Dysentery) from <5a?,bad or difficult, and
evTffoii, an intestine. — [Both the genera of this order
are misplaced. They belong to the order Phleg-
masiae. — Ed.]

CLASS II.
NEUROSES, (Nervous Diseases) from nvgov, a nerve.

TABULAR VIEW. 75

ORDER I.

C omata, (Soporose Diseases) from ku(4m, a propensity to sleep.
Genus 42. Apoplexia, (apoplexy) from etna and t^o-o-u, to strike
down.

Sanguinea, from blood.

Serosa, from serum.

Hydrocephalica, from water. — [This be-
longs to the order Phlegmasia. — Ed.~\
43. Paralysis, (Palsy) from nctectXvu, to loose.
Tremor, (Trembling').'

ORDER II.

Adynamic, (Want of Power) from a. privative, ^weepa, power.
Genus 44 Syncope, (Fainting-) from «-t/v, and kok^u, to cut or strike
down.

45. Dyspepsia, (Indigestion) from «%?, bad, and Twrru, to

concoct. i

46. Hypochondriasis, (Hypochondriac Affections) from

v7r«%o)ifytxxos, one who is hipped — from two, under,
and ^avo^es, a cartilage — i. e. an affection of the liver,
which is situated under the cartilages of the false
ribs.
47. Chlorosis, (Green Sickness) from %>Mgos, green. — [This
disease is misplaced: it belongs either to Amenor-
rhoea or to the order Profluvia. — Ed.]

ORDER III.

Spasmi, (Spasmodic Diseases) from o-sraw, to draw.
Genus 48. Tetanus, (General Cramp) from reiva, to stretch.

49. Convulsio.(Co?zx>w£s2Grc)from con vello, to pull or pluck.

50. Chorea, (St. Vitus' s Dance) from x°? £iX i a dance.

51. Raphania, (Raphany) — so called because supposed to

be produced by the seeds of the raphanus raphanis-
trum.

52. Epilepsia, (Epilepsy) from tfn and Xoc^ettvu, to seize 3

because it attacks or seizes suddenly.

53. Palpitatio, (Palpitation, or violent and irregular beat-

ing of the heart).

54. Asthma, (Asthma) from ess-fytot^y, to breathe with diffi-

culty.

55. Dyspnoea, (A Difficulty of Breathing) from ©V, bad,

and 5Tve», to breathe.

76 TABULAR VIEW

Genus 56. Pertussis, (Hooping Co ugh ) from per, x\\uc\\,M\<\tussis,
a cough.

57. Pyrosis, ( Water Brash) from Trvgatrts, a burning.

58. Colica, (Colic) from *oA«v, the largest of the intestines.

59. Cholera, ( Vomiting and Purging) from %oM, bilc > an(1

peu, to flow .

60. Diarrhoea, (Purging) from <^«, through, and peu, to flow.

— [This and Cholera belong more properly to the
order Profluvia. — Ed.~]

61. Diabetes, (An Excessive Discharge of Urine) from <5W,

through, and fixtva, to pass. [This would seem also
to belong to the order Profluvia. — EdJ]

62. Hysteria, (Hysteric Disease) from veepec, the womb.

63. Hydrophobia, (Canine Madness) from v$ca% , water, and

AoZeu, to fear.

ORDER IV.

VesanIjE, (Menial Diseases) from vesania, madness.
Genus 64. Amentia, (Idiotism) from <*, privative, and r*m, the mind.
65. Melancholia, (Melancholy) from fteA*?, black, and #<>A>?,
bile ; because supposed to arise from a vitiated con-
dition of the bile.
66 Mania, (Madness) from f^tivo^xi, to rage.
67. Oneirodynia, (Disturbed Sleep) from omgo<;, a dream,
and aJW)?, pain.

CLASS III.
CACHEXIA, (Cachectic Diseases) from xcckos, bad, and e|<?> a
habit.

ORDER. I.
Marcores,( Universal Emaciation).
Genus 68. Tabes, (Consumption).

Purulenta. — [This, and most of the subsequent

ones, belong to the order Phlegmasia. — Ed.~]

Renalis.

Hepatica.

- e Stomacho.

e Pericardio.

Catarrhalis.

Scrophulosa.

Rachitica.

Venenata.

69. Atrophia, (Atrophy) from a, priv. and rpo<p>i, nourishment.

TABULAR VIEW. 77

ORDER II.

IntumescentijE, ( General Swellings).

SECTION I.

AdiposjE, (Consisting of Fat).
Genus 70. Polysarcia, (Corpulency) from *reA«/s, much, and «■*$!,
flesh.

SECTION II.

Flatuos^e, (Consisting of Wind).

Genus 71. Pneumatosis, (An Air Swelling) from irnvpuxraTis,

from 7rvev(A.a,, breath, from 9rve«, to breathe.

72. Tympanites, (Tympany) from Tvpunrent^u, to soundlike

a drum.

73. Physometra, ( Tympany of the Womb).

SECTION III.

AquoSiE sive Hydropes, (Consisting of Water).

Genus 74. Anasarca, (Dropsy of the Cellular Membrane) from

«v«, along or through, and e-«f|, the flesh.

75. Hydrocephalus, (Dropsy of the Head) from vfrag, wa-

ter, and x.e<p*to, the head.

76. Hydrorachitis, (a Watery Swelling) generally seated

in the spinal marrow.

77. Hydro thorax, (Dropsy of the Chest) from vfrug, water,

and £»/>«f , the chest.

78. Ascites, (Dropsy of the Belly) from ««-ko?, a sack.

79. Hydrometra, (Dropsy of the Womb) from vS'ag, water,

and iwrga, the womb.

80. Hydrocele, (Dropsy of the Tunica Vaginalis Testis)

from vfup, water, and kjj^uj, a swelling.

81. Physconia, (Physcony) an intumescence of the abdo-

men, from an enlargement of some of its contents.

82. Rachitis, (Rickets) from £<*#/?, the spine of the back.

ORDER III.

Impetigines, (Cutaneous Diseases) from in, and petigo, a scab.

Genus 83. Scrophula, (Scrofula, or King's Evil) from scrofula, a

swine, that animal being subject to a similar disease.

84. Syphilis, ( Venereal Disease) from c-^Aa?, filthy.

85. Scorbutus, (Scurvy).

86. Elephantiasis, (Leg swelled and Skin thickened like

that of an Elephant) from sAep«s, an elephant.

78 TABULAR VIEW.

Genus 87. Framboesia, ( Yaws) from framboise, in French, a rasp-
berry.

88. Lepra, (Lefirosy) from Aezn«, a scale.

89. Trichoma, (Plica Polonica,or Plaited Hair).

90. Icterus, (Jaundice) from ucre^t, the jaundice.

CLASS IV.
LOCALES, (Local Diseases.)

' ORDER I.
Dysesthesia, (Diseases of the Senses) from S~vg, bad, and cti<r8t)rts f

feeling.
Genus 91. Caligo, (Im/iaired Vision,from an opacity in the coats

or humours of the Rye.)

92. Amaurosis, (Gutta Serena, or Loss of Vision without

any Opacity) from etfMtvgws, obscurity.

93. Dysopia, (Difficult Vision) from $vi, bad or difficult,

and airs, an eye.

94. Pseudoblepsis, (False Vision) from ^ivfos, false, and

/3AeiT(W. to see.

95. Dyseccea,(Z)ea/>zess)from JWe*o/« — from ^t/s, bad, and

ccx.au, to hear.

96. Paracusis, (Depraved Hearing) from -zrx^x, wrong, and

cckxu, to hear.

97. Anosmia, (Loss of Smell) from«, privative, and a^a, to

smell.

98. Agheustia, (Loss of Taste) from «, privative, and

yenofcxi, to taste.

99. Anaesthesia, (Loss of Touch) from x, privative, and

uKrOqtrif, feeling.

ORDER IT.

DYHOKRxiM,(Depraved appetites) from <JVs, bad, and e£ff<s, appe-
ar tite.

SECTION I.

Appetitus Erronei, (False Afifietites).
Genus 100. Bulimia, (Canine or Inordinate Appetite) from j3*?,an
ox, and Aifie<, hunger.

101. Polydipsia, (Inordinate Thirst) from vaAv«, much, and

hiro-is, thirst.

102. Pica, (Vitiated Afip.etite).

103. Satyriasis, (Inordinate Lust in Men) from o-xtv^ixth.

TABULAR VIEW. 79

Genus 104. Nymphomania,(iircordmate Lust in TVomen)from wfi-
<P», a nymph, and /Minx, madness.
105. Nostalgia, (Home Sickness).

SECTION 11.
Appetitus Deficientes, (Defective Appetites).
Genus 106. Anorexia. (Loss of Appetite) from «, privative, and
opffi«, appetite.

107. Adypsia, ( Want of Thirst) from «, privative, and

h-xo-ct, thirst.

108. Anaphrodisia, (Impotence) from <*, priv. and *p§ec^?«*,

venery.

ORDER III.

Dyscinesi^:, (Depraved or Impeded Motion) from <5"t>$, bad, and

uvea, to move.
Genus 109. Aphonia, (Loss of Voice) from <*, privative, and pavy,

the voice.

110. Mutitas (Dumbness).

111. Paraphonia, (Harsh or Depraved Voice) from zr*f«,

bad, and p«v», the voice.

112. Psellismus, (Stammering).

113. Strabismus, (Squinting) from «-£<*C<£«y, to squint.

1 1 4. Dysphagia, (Impeded Deglutition) from JVs, and <p*ya,

to eat.

115. Contractura, (Contraction of the Joints).

ORDER IV.

ApocENOsES,(/rccrea.setf Discharges)hom ccx-oxmu, to move from.
Genus 116. Profusio, (Passive Hamorrhagy).

117. Ephidiosis, (Excessive and Morbid Sweating) from

itptfyea, to sweat.

118. Epiphora, (Profusion of Tears).

119. Ptyalismus, (Profusion of Saliva) from <pto, to spit.

120. Eneuresis, (Involuntary Discharge of Urine).

121. Gonorrhoea, (a Preternatural Mucous or Puriforvi

discharge from the Urethra in Males) from yon
semen, and f e&», to flow.

ORDER V.

Epischesis, (Obstructions) from e-ri^co;^ a suppression or ob-
struction.
Genus 122. Obstipatio, (Costiveness) from obstifio, to stop up.

80 TABULAR VIEW.

Genus 123. Ischuria, {Suppression of Urine) from i<r%<->, to restrain,
and «fev, urine.

124. Dysuria, {Difficulty in Discharging Urine) from <JV«,

difficult, and «fev, the urine.

125. Dyspermatismus, {An Impeded Emission of Semen)

from ^ and ^eg/ix, semen.

126. Amenorrhea, {a Retention of the Menses) from*,

priv. fMivtxtos, monthly, and fe», to flow.

ORDER VI.

Tumores, {Tumours) from tmmeo, to swell.
Genus 127. Aneurisma, {Aneurism).

128. Varix, {a Local Enlargement of a Vein).

129. Ecchymoma, {a Tumour formed by the Effusion of

Blood into the Cellular Membrane) from e|, xcv, to
pour out, and ctip.it., blood.

130. Schirrus, {An Indolent Swelling for the most part of

a Gland).

131. Cancer, {Cancer).

132. Bubo, {a Swelling of a Conglobate Gland).

133. Sarcoma, {a Fleshy Enlargement) irom o"«f|, flesh.

134. Verruca, (a Wart).

135. Ulavus,(a Corn).

136. Lupia, {a soft moveable Tumour situated under the

skin, usually in a tendinous fiart.)

137. Ganglion, {a hard moveable Tumour resting on a

tendon).

138. Hydatis, {a Watery Tumour) from vfag, water.

139. Hydarthrus, ( White Swelling of the Joint) from vty,

water, and xgdgov, a joint.
140 Exostosis, {An Enlargement of a Bone) from tg and
«s"tov, a bune.

ORDER VII.

Ectopia {Displacements) from ef, from, and roTot, a place.
Genus 141. Hernia, {Rupture or Displacement of Soft Parts).

142. Prolapsus, {The Falling down of a Part) from pr»

and labor, to fall down.

143. Luxatio, {Displacement of a Bone).

ORDER VIII.

Dyalyses, {Division of Parts) from h», and Ava, to divide or
separate.

TABULAR VIEW. 81

Genus 144. Vulnus, {a Wound) a recent division of a soft part,
accompanied with a haemorrhag. .

145. Ulcus, {An Ulcer) a division of a soft part, accompa-

nied by a purulent or ichorous discharge.

146. Herpes, {Tetters) from epiru, to creep.

147. Tinea, ( Tetter among the Hair).

148. Psora, {The Itch) from ?nr«£«, a scab.

149. Fractura, {Division of a Bone) from frango, to break

150. Caries, {Rottenness or Mortification of a Bone).

VOL. I.

FIRST LINES

OF THE

PRACTICE OF PHYSIC.

INTRODUCTION.

1. IN teaching the Practice of Physic, We endeavout
to give instruction for discerning, distinguishing, pre-
venting, and curing diseases, as they occur in particular
persons.*

* This article contains a very clear, sticcinct and comprehensive view of
the intellectual operations and practical duties of the physician in his inter-
course with diseases. His first business is to discern them — i. e. to ascertain
their existence, by his knowledge of the .difference between the phenomena
of health and those of disease. He must next distinguish between one dis-
ease and another. By this operation of his mind he attains a knowledge of
the nature and character of the existing disease, without which he would be
utterly incompetent to its treatment.

Were all diseases an unit, this process of discrimination would be wholly
unnecessary — indeed the very attempt at it would be preposterous. In such
a case, the instant the mere existence of disease was ascertained, the practi-
tioner might commence his treatment without the least circumspection or
choice as to the remedy to be employed. Were disease an unit, practice
would be also an unit; and therefore one remedy would be just as suitable
as a ther. If all diseases be the same, where is the necessity, or even the
ground, for that vigilance of attention, which the late Dr. Rush so zealously
and properly inculcated, to "the state of the system." In what but "the
state of the system" does disease consist? - II all diseases be the same, there-
fore, all " states" are also the same: and hence the act of discrimination as to
disease is superfluous*

In his attempts to prevent diseases, the physician reduces to practice his
knowledge of the principles of prophy laxis, which is clearly his duty. Their
treatment or cure constitutes his last practical process. To accomplish this,,
*s he ought, cenb, cilb, et tutd, requires a happy combination of multifariour

84- PRACTICE OF PHYSIC

2. The art of discerning and distinguishing dis-
eases, may be best attained by an accurate and complete
observation of their phenomena, as these occur in con-
course and in succession, and by constantly endeavour-
ing to distinguish the peculiar and inseparable concur-
rence of symptoms, to establish a Methodical Noso-
logy, or an arrangement of diseases according to their
genera and species, founded upon observation alone,
abstracted from all reasoning. Such an arrangement
I have attempted in another work, to which, in the
course of the present, I shall frequently refer.*

3. The prevention of diseases depends upon the
knowledge of their remote causes; which is partly deli-
vered in the general Pathology, and partly to be deli-
vered in this treatise.f

knowledge. He must be as thoroughly versed in the qualities and proper-
ties, the preparation, composition, and administration of remedies, as he is in
the nature, character, and variations of diseases. Hence a great physician,
in the true sense of the word, is as seldom found as a great general.

* We discern and distinguish diseases precisely as we do all other objects
of nature ; by a strict attention to their external qualities. But the external
or only perceptible qualities oT diseases, are their signs and symptoms. It
is on these, therefore, that our attention must be fixed, if we wish to acquire
a knowledge of their character.

f In the language of the schools, the causes of disease are divided, first,
into remote and proximate. The remote causes are again divided i»to pre-
disposing and exciting or occasional.

The remote predisposing cause is that, which, by its agency on the human
body, produces in it a predisposition or strong liability to disease. The re-
mote occasional cause is that, which, by its influence on the body, when thus
predisposed, gives rise to actual disease.

The predisposing cause of intermitting fever is marsh miasma; the occa-
sional or exciting cause, exposure to a shower of rain or the night air, to
cold or to excessive fatigue.

The predisposing cause of influenza is an aerial poison, or something pe-
culiarly deleterious in the condition of the atmosphere ; the exciting cause,
the same as in the case of intermitting fever.

Were occasional causes strictly avoided, the predisposing cause would be,
in most instances, deprived of its power to injure. This, however, is not
always the case. In some diseases the predisposing is also the occasional
cause. This is certainly the case in small pox, kine pox, and, we believe, in
every disease that is truly contagious. Contagion, in the strict sense of the

PRACTICE OF PHYSIC. 85

4. The cure of diseases is chiefly, and almost un-
avoidably founded in the knowledge of their proximate
causes. This requires an acquaintance with the insti-
tutions of medicine; that is, the knowledge of the struc-
ture, action, and functions of the human body; of the
several changes which it may undergo; and of the
several powers by which it can be changed. Our
knowledge of these particulars, however, is still incom-
plete, is in many respects doubtful, and has often been
involved in mistake and error. The doctrine, there-
fore, of proximate causes, founded upon that know-
ledge, must be frequently precarious and uncertain. It
is, however, possible for a judicious physician to avoid
what is vulgarly called theory, that is, all reasoning
founded upon hypothesis, and thereby many of the
errors which have formerly taken place in the institu-
tions of medicine. It is possible also for a person who
has an extensive knowledge of the facts relative to the
animal economy in health and sickness, by a cautious
and complete induction, to establish many general prin-
ciples which may guide his reasoning with safety; and
while, at the same time, a physician admits as a founda-
tion of practice those reasonings only which are simple.

term, is a poison which gives rise to its specific effect, independently of
every auxiliary cause. It both predisposes to and excites the disease it pro-
duces. If it did not do this, it would cease to be a poison.

The chief differences between contagion and other poisonous substances
is, that the former acts without any nice dependence on dose or quantity — a
small dose being as capable of doing mischief as a large one — and, that it is
competent to the business of self-propagation, by exciting, in living matter,
such a specific state of action as reproduces itself. It is possessed of a kind
of generative power, which is not the case with any other poison. Although
the morbid action produced by arsenic destroys life, it does not produce
arsenic as one of its results.

During the prevalence of an epidemic, which is but another name for a
disease of atmospheric origin, every person is liable to an attack of it, be-
cause he is under the influence of the remote predisposing cause. His only
security, therefore, consists in a strict avoidance of exciting causes.

86 PRACTICE OF PHYSIC.

obvious, and certain, and for the most part admits as
proximate causes those alone that are established as
matters of fact rather than as deductions of reasonings
he may, with great advantage, establish a system of
practice chiefly founded on the doctrine of proximate
causes. But when this cannot be done with sufficient
certainty, the judicious and prudent physician will have
recourse to experience alone; always, however, aware
of the hitherto incomplete and fallacious state of em-
piricism.*

5. With a strict attention to these considerations in
the whole of the following treatise, I proceed to treat
of particular diseases in the order of my Methodical
Nosology.

* The proximate cause is the effect produced by means of the predispos-
ing and exciting causes. It is, in other words, the morbid action in which
the disease itself consists. This, therefore, did we in all cases possess a full
and satisfactory knowledge of it, would constitute unquestionably the best
foundation on which to erect our plan of cure.

Had we unequivocal evidence that a certain disease consists in a spasm of
a particular organ, and did we possess a remedy perfectly calculated to re-
move that spasm, the exhibition of such remedy would constitute the fulfil-
ment of the true and only indication. Did another disease consist, with
certainty, in an excess of vascular action in a particular part, and were we
in possession of a remedy or mode of practice precisely calculated to reduce
that action, we could be at no loss as to the measures necessary to be pur-
sued. Did a third disease consist in a defective action of the secretory ves-
sels of the kidneys, and had we a remedy we could confidently rely on as a
diuretic, the exhibition of that remedy should constitute our practice. This
would be treating diseases in a manner truly rational and scientific — a man-
ner that could not fail to add to the utility, as well as to the dignity and eleva-
tion of our profession.

But we have to regret that our knowledge of the human system, whether
in health or disease, is not sufficient to warrant us in the attempt to prac-
tise at all times on first principles. Although our acquaintance with the na-
ture of diseases directs us, in part, in our mode of treating them, we must
also, in part, rely on our experience. We apprehend that we are indebted
more to the latter, and less to the former source, than Dr. Cullen seems -will-
ing to allow

PRACTICE OF PHYSIC. $7

PAJRT I.

OF PYREXIA, OR FEBRILE DISEASES.

o*. PYREXIAE, or febrile diseases, are distinguished
by the following appearances. After beginning with
some degree of cold shivering, they show some increase
of heat, and an increased frequency of pulse, with the
interruption and disorder of several functions, particu-
larly some diminution of strength in the animal func-
tions*

7. Of these Pyrexiae I have formed a class, and have
subdivided it into five orders of fevers, inflammations,
eruptions, hemorrhagies, and fluxes. — See Synop-
sis Nosologias Methodicas, Edit 3. 1780.

BOOK. I.

OF FEVERS.

CHAPTER I.
OF THE PHENOMENA OF FEVERS.

8. THOSE diseases are more strictly called fever*.
which have the general symptom of Pyrexia, without

* In his definition of pyrexiae or febrile diseases, our author makes use ofan
expression which we think too strong. « After beginning with some degree
of cold shivering," &c.

That febrile diseases are ushered in by a sensation of coldness is true;
but it is equally true, that this sensation does not, at all times, nor, perhaps,
as a general rule, amount to a shivering. In many of the most violent and ma-

88 PRACTICE OF PHYSIC.

having along with them any topical affection that is
essential and primary, such as the other orders of the
Pyrexiae always have.

9. Fevers, as differing in the number and variety of
their symptoms, have been very properly considered as
of distinct genera and species. But we suppose that
there are certain circumstances in common to all the
diseases comprehended under this order, which are
therefore those essentially necessary to, and properly
constituting the nature of fever. It is our business es-
pecially, and in the first place, to investigate these ; and
I expect to find them as they occur in the paroxysm, or
fit, of an intermittent fever, as this is most commonly
formed.

10. The phenomena to be observed in such a pa-
roxysm are the following. The person is affected, first,
with a languor or sense of debility, a sluggishness in
motion, and some uneasiness in exerting it, with fre-
quent yawning and stretching. At the same time, the
face and extremities become pale; the features shrink;
the bulk of every external part is diminished; and the
skin over the whole body appears constricted, as if
cold had been applied to it. At the coming on of
these symptoms, some coldness of the extremities,
though little taken notice of by the patient, may be per-

lignant cases of disease, the cold stage is so slight as to be scarcely percep-
tible.

Nor is it true that the pyrexia actually begin with a sensation of coldness.
That symptom does not constitute the first link in the chain of disease. It
is itself the effect of a preceding link, viz. the local irritation produced by
the immediate agency of the febrile cause. In the whole of Dr. Cullen's
order Febris, as well as in many other febrile complaints, we feel persuaded,
as we have already observed, that the original topical affection takes place
in the stomach. This constitutes the seat and centre of the disease ; whence,
asfromapunctum saliens, or point of action, it extends by sympathy through-
out the system. Hence the importance, especially in the early stage of
these complaints, of directing 'iur attention to the state of the stomach This
subject shall be resumed and more fullv considered on a subsequent occasion.

PRACTICE OF PHYSIC. 89

ceived by another person. At length, the patient him-
self feels a sensation of cold, commonly first in his
back; but, from thence, passing over the whole body;
and now his skin feels warm to another person The
patient's sense of cold increasing, produces a tremor in
all his limbs, with frequent successions or rigours of
the trunk of the body. When this sense of cold, and
its effects, have continued for some time, they become
less violent, and are alternated with warm flushings. By
degrees, the cold goes off entirely; and a heat, greater
than natural, prevails, and continues over the whole
body. With this heat, the colour of the skin returns,
and a preternatural redness appears, especially in the
face. Whilst the heat and redness comes on, the skin
is relaxed and smoothed, but for some time continues
dry. The features of the face, and other parts of the
body, recover their usual size, and become even more
turbid. When the heat, redness, and turgescence have
increased, and continued for some time, a moisture ap-
pears upon the forehead, and by degrees becomes a
sweat, which gradually extends downwards over the
whole body. As this sweat continues to flow, the heat
of the body abates; the sweat, after continuing some
time, gradually ceases; the body returns to its usual
temperature; and most of the functions are restored to
their ordinary state.*

11. This series of appearances gives occasion to di-
vide the paroxysm into three different stages; which
are called the cold, the hot, and the sweating
stages, or Fits.

In the course of these, considerable changes happen

* It is but justice to Dr. Cullen to remark, that this and the following
sections contain the most perfect picture of a paroxysm of intermitting
fever that is any where to be found. Indeed, his descriptions of diseases, in
general, are possessed of such accuracy and excellence, as to leave the
practitioner but little to wish for on that subject.
VOL. I. M

90 PRACTICE OF PHYSIC.

in the state of several other functions, which are now
to be mentioned.

12. Upon the first approach of languor, the pulse be-
comes sometimes slower, and always weaker than be-
fore. As the sense of cold comes on, the pulse becomes
smaller, very frequent, and often irregular. As the cold
abates and the heat comes on, the pulse becomes more
regular, hard, and full; and in these respects, increases
till the sweat breaks out. As the sweat flows, the pulse
becomes softer, and less frequent, till the sweat ceasing
altogether, it returns to its usual state.

13. The respiration also suffers some changes. During
the cold stage, the respiration is small, frequent and
anxious, and is sometimes attended w:ith a cough: as
the hot stage comes on, the respiration becomes fuller
and more free; but continues still frequent and anxious,
till the flowing of the sweat relieves the anxiety, and
renders the breathing less frequent and more free. With
the ceasing of the sweat, the breathing returns to its
ordinary state.*

. * In respiration the patient experiences a kind of asthmatic stricture and
anxiety. This no doubt arises from a direct sympathy between the sto-
mach and lungs, which is oftentimes, at least, if not generally, the source
of real asthfpa. Hence, in that disease, the advantages derived from eme-
tics and other remedies that operate on the stomach. A dose of tartar eme-
tic has sometimes prevented a paroxysm of asthma, when exhibited as soon
as the threatenings were felt.

During the cold stage of an intermittent, there appears to exist on the
surface of the lungs a real spasm, at least a want of healthy action, in con-
sequence of which that organ is disqualified for the performance of its
duty in relation to the blood.

This spasm or stricture, prevailing also in the mouth, on the tongue, and
in the fauces, and preventing secretion there, appears to be the cause of
the troublesome thirst that is felt. It relaxes only with the relaxation of
that on the surface of the body, which is manifested by the free and copi-
ous flowing of the sweat. On the occurrence of this, the thirst and diffi-
culty of respiration cease.

The process of puking, whether it arise spontaneously or be produced by
art, is known to operate favourably in exciting a sweat, and in relieving thirst
and anxious respiration. This shows, we think, with sufficient clearness,

PRACTICE OF PHYTIC. 9]

14. The natural functions also suffer a change. Upon
the approach of the cold state, the appetite for food
ceases, and does not return till the paroxysm be over,
or the sweat has flowed for some time. Generally
during the whole of the paroxysm, there is not only a
want of appetite, but an aversion from all solid, and es-
pecially animal food. As the cold stage advances, there
frequently comes on a sickness and nausea, which often
increase to a vomiting of a matter that is for the most
part bilious. This vomiting commonly puts an end to
the cold stage, and brings on the hot. As the hot stage
advances, the nausea and vomiting abate; and when the
sweat breaks out, they generally cease altogether.

15. A considerable degree of thirst is commonly felt
during the whole course of the paroxysm. During the
cold stage, the thirst seems to arise from the dryness
and clamminess of the mouth and fauces, but during
the hot stage, from the heat which then prevails over
the whole body; and as the sweat flows, the mouth be-
comes moister, and the thirst, together with the heat,
gradually abates.

16. In the course of a paroxysm, there is often a
considerable change in the state of the secretions. The
circumstances just now mentioned, show it in the se-

that these symptoms arise from the same cause, and that they are closely
associated with the state of the stomach.

On these points, the explanation we attempt is somewhat different from
that of Dr. Cullen. The reader is at liberty to choose between us.

Under the present head we shall only further observe, that the limpid
state of the urine, the drying up of ulcers on the surface of the body, and
the detumescence of tumours, are. in our estimation, most easily and satis-
factorily explained, by admitting the existence and action of spasm By this
term we mean a morbid contraction produced by immediate or sympathetic
irritation.

It is owing, perhaps, to the operation of the same cause, that a mercurial
salivation is suspended during a paroxysm of intermittent, but recurs on the
return of a state of pyrexia. This, although not a very frequent, is a well
known phenomenon.

92 PRACTICE OF PHYSIC.

cretion of the saliva ami mucus of the mouth; and it is
still more remarkable with respect to the urine. During
the cold stage, the urine is almost colourless, and with-
out cloud or sediment. In the hot stage it becomes
high coloured, but is still without sediment. After the
sweat has flowed freely, the urine deposits a sediment,
commonly lateritious, and continues to do so for some
time after the paroxysm is over.

17. Excepting in certain uncommon cases which are
attended throughout with a diarrhoea, stools seldom oc-
cur till towards the end of a paroxysm, when commonly
a stool happens, which is generally of a loose kind.

18. Analogous to these changes in the state of the
secretions, it frequently happens that tumours subsist-
ing on the surface of the body, suffer, during the cold
stage of fevers, a sudden and considerable detume-
scence; but generally, though not always, the tumours
return to their former size during the sweating stage.
In like manner, ulcers are sometimes dried up during
the cold stage; and return again to discharge matter
during the sweating stage, or after the paroxysm is
over.

19. Certain changes appear also in sensation and
thought. During the cold stage, the sensibility is often
greatly impaired; but when the hot stage is formed,
the sensibility is recovered, and often considerably in-
creased.

20. With respect to the intellectual functions, when
the cold stage comes on, attention and recollection be-
come difficult, and continue more or less so during the
whole paroxysm. Hence some confusion of thought
takes place, and often arises to a delirium, which some-
times comes on at the beginning of the cold stage, but
more frequently not till the hot stage be formed.

21. It belongs also to this place to remark, that the

PRACTICE OF PHYSIC. 93

cold stage sometimes comes on with a drowsiness and
stupor, which often increase to a degree that may be
called comatose, or apoplectic*

22. We have still to add, that sometimes, early in the
cold stage, a headach comes on; but which, more com-
monly, is not felt till the hot stage be formed, and then
is usuall) attended with a throbbing of the temples. The
headach continues till the sweat breaks out; but as this
flows more freely, that gradually goes off. At the same
time with the headach, there are commonly pains of
the back, and of some of the great joints; and these
pains have the same course with the headach.

23. These are nearly the whole, and are at least the
chief of the phenomena which more constantly appear
in the paroxysm of an intermittent fever; and we have
pointed out their ordinary concourse and succession.
With respect to the whole of them, however, it is to be
observed, that in different cases, the several phenomena
are in different degrees; that the series of them is more
or less complete; and that the several parts or stages in
the time they occupy, are in a different proportion to
one another.

24. It is very seldom that a fever consists of a sin-
gle paroxysm, such as we have now described; and it
more generally happens, after a certain length of time
has elapsed from the ceasing of the paroxysm, that the
same series of phenomena again arises, and observes
the same course as before; and these states of fever
and apyrexia often continue to alternate with one
another for many times. In such cases, the length of
time from the end of one paroxysm to the beginning of

* The comatose state spoken of in this section is much relieved, if not
effectually removed, by the exhibition of an emetic. It arises from sympa-
thy between the stomach and brain. In some cases of it blood-letting be-
comes necessary.

94 PRACTICE OF PHYSIC.

another, is called an intermission; and the length of
time from the beginning of one paroxysm to the begin-
ning of another next succeeding, is called an interval.
25. When the disease consists of a number of pa-
roxysms, it is generally to be observed, that the inter-
vals between them are nearly equal; but these inter-
vals are of different lengths in different cases. The
most usual interval is that of forty-eight hours, which
is named the tertian period. The next most com-
mon is that of seventy-two hours, and is named the
quartan period. Some other intervals are also ob-
served, particularly one of twenty-four hours, named
therefore, the quotidian; and the appearance of this
is pretty frequent. But all other intervals longer than
that of the quartan are extremely rare, and probably
are only irregularities of the tertian or quartan pe-
riods*

* We have some doubts as to the correctness of a part of this article, par-
ticularly as applied lo the United States. If we be permitted to rely on our
own observation, we must believe, that, instead of being a more frequent,
the quartan ague is a less frequent form of the disease than the quotidian.
In the southern stales, quotidian intermittent* are often seen, quartans more
rarely ; and much more rarely still does the disease assume the quartan form
at its commencement. Quartans are more frequently formed out of ter-
tians and quotidians, when unusually protracted.

Of tertian and quartan intermittents there are several varieties. The fol-
lowing may be enumerated as of the most frequent occurrence. The dou-
ble tertian, having a paroxysm everyday, with the alternate paroxysms
alike. The double tertian, with two paroxysms every other day. The triple
tertun, with two paroxysms on one day, and one on the next. The double
quartan, with two paroxysms on the first day, none on the second and third,
and 'wo again on the fourth. The double quartan, with a paroxysm on the
first day, and another on the second, but none on the third. The triple
quartan, with three paroxysms every fourth day. The triple quartan, with
a paroxysm every day, every fourth paroxysm beng alike.

Under our own observation all these varieties have never fallen : but they
are familiarly mentioned in the writings of authors whose experience has
been ample We are not, therefore, permitted to doubt of their existence.

The most singular circumstance in the history of intermittents, and, in-
deed, one of the most curious and inexplicable in any way connected with
medical science, is the periodical character of those complaints. Why an

PRACTICE OF PHYSIC. 95

26. The paroxysms of pure intermittent fevers are
always finished in less than twenty-four hours: and

irritation so severe as to have produced the most violent and distressing-
fever, should become perfectly dormant, and having remained so for '.he
space of twelve, thirty-six, or sixty-two hours, recur in all its original
strength, to pursue again the same course? and why this order of things
should continue for months, and even years ? are questions which have
never been satisfactorily answered.

It has, indeed, been said, and may be, perhaps, again, that the excitability
of the part immediately acted on by the morbific cause, having become ex-
hausted by the violence of impression, requires, for its restoration, the
lapse of a definite period; and that this restoration is no sooner effected,
than the original cause, acting again, reproduces its original train of phe-
nomena. But this position, admitting it to be true, is nothing but a simple
statement of a fact, instead of an assignment of an efficient cause. Far from
affording an explanation, therefore, it is itself a subject difficult to be ex-
plained.

Some writers, in their attempts to solve the problem of the periodical na-
ture of the intermittent, have added to the supposed effect of exhausted
and renovated excitability, the influence of the solar or lunar day. Oihers,
the influence of the earth revolving on its own axis, connected with that of
electricity and gravitation, as being uniformly the same at given hours, and'
calculated, therefore, for the production of the same effect. Others again
have attributed the phenomena to the force of habit, and the identity of
impression produced by an identity of causes in us and around us at given
hours. In the wildness and multifarious resources of conjecture, still fur-
ther hypotheses have been attempted on this subject, the very recital of
which we should deem an inadmissible consumption of time.

In the present state of medical science, we are apprehensive that all we
can honestly do is, to assume the periodical nature of intermittents as an
ultimate fact, and refer it to a law of our nature not yet explained. We are
the more strongly inclined to this opinion, in consideration of the periodi-
cal character of many other complaints besides intermittents.

Insanity and epilepsy are periodical diseases : so, in like manner, are
asthma and gout. In tetanus, the muscular spasms intermit and recur, with-
out any apparent cause for such changes. So do the pains of colic, the
gripings in diarrhoea, the tormina of dysentery, and the throes of parturi-
ency. In these cases, more especially in tetanus, colic and the parturient
process, the presence of the irritating cause is uniform, while its effects are
intermitting. In them therefore, no less than intermittents, the suspension
of the irritation takes place under the influence of the irritating cause.
These, with many other kindred facts, we are forced to refer to the same
original law of our nature from which we would derive the phenomena of
intermittents. They are inexplicable, at present ; although a single disco-
very may fortunately hereafter explain them all.

To the same law do we appear to be indebted for many of the most fami-
liar phenomena of health. Of these we might mention, in particular, the

96 PRACTICE OF PHYSIC.

though it happens that there are fevers which consist of
repeated paroxysms, without any entire intermission
between them; yet in such cases it is observed, that
though the hot "and sweating stages of the paroxism
do not entirely cease before the twenty-four hours from
their beginning have expired, they suffer, however, be-
fore that time, a considerable abatement or remission
of their violence; and at the return of the quotidian
period, a paroxysm is in some shape renewed, which
runs the same course as before. This constitutes what
is called a remittent fever

21. When in these remittents the remission is consi-
derable, and the return of a new paroxysm is distinctly
marked by the symptoms of a cold stage at the begin-
ning of it; such fevers retain strictly the appellation of
remittents. But when it happens, as it does in cer-
tain cases, that the remission is not considerable, is per-
haps without sweat, and that the returning paroxjsm
is not marked by the most usual symptoms of a cold
stage, but chiefly by the aggravation or exacerbation
of a hot stage, the disease is called a continued fever.

28. In some cases of continued fever, the remissions
and exacerbations are so inconsiderable as not to be
easily observed or distinguished; and this has led phy-
sicians to imagine, that there is a species of fever sub-
sisting for several days together, and seemingly, con-
sisting of one paroxysm only. This they have called a
continent fever; but, in a long course of practice, I
have not had an opportunity of observing such a fever.

29. It is, however, to be observed here, that the
fevers of a continued form are to be distinguished from

recurrence, at stated periods, of the appetites of hunger and thirst, the
call to evacuate the urine and faeces, the disposition to sleep and awake,
with such other actions and states of the system as are under the influence
of habit.

PRACTICE OF PHYSIC. 97

one another; and that, while some of a very continued
form do still belong to the section of intermittents, there
are others which, though still consisting of separate
and repeated paroxysms, yet as different from their
causes and circumstances from intermittents, are to be
distinguished from the whole of these, and are more
strictly to be called and considered as continued.
Such are most of those which have been commonly
supposed to be continent; and those which by moat)
writers have been simply named continued; and wtticli
term I have employed as the title of a section, to be'
distinguished from that of intermittent.

I shall here add the marks by which, in practice,
these different continued fevers may be distinguished
from one another.

Those fevers of a continued form, which, however,
still belong to the section of Intermittents, may be dis-
tinguished by their having passed from an intermittent
or remittent form, to that of a continued; by their
showing some tendency to become intermittent, or at
least remittent; by their being known to have been
occasioned by marsh miasmata; and, for the most part,
by their having but one paroxysm, or exacerbation and
remission, in the course of twenty-four hours.

On the other hand, Continued Fevers, to be more
strictly so called, may be distinguished by their show-
ing little tendency to become intermittent or remittent
in any part of their course, and especially after the
first week of their continuance; by their being occasion-
ed by human contagion, at least by other causes than
the marsh miasmata; and by their having pretty con-
stantly an exacerbation and remission twice in the
course of twenty-four hours. In both cases, the know-
ledge of the nature of the epidemic for the time pre-

VOL. I. N

98 PRACTICE OF PHYSIC.

vailing, may have a great share in determining the na-
ture of the particular fever.

30. With respect to the form, or type of fevers, this
further may be observed, That the quartan, while it has
the longest interval, has. at the same time, the longest
and most violent cold stage; but, upon the whole, the
shortest paroxysm: That the tertian, having a shorter
interval than the quartan, has, at the same time, a short-
er and less violent cold stage; but a longer paroxysm:
And lastly, that the quotidian, with the shortest inter-
val, has the least of a cold stage; but the longest pa-
roxysm.

31. The type of fevers is sometimes changed in their
course. When this happens, it is generally in the fol-
lowing manner: Both tertians and quartans change into
quotidians, quotidians into remittents, and these last be-
come often of the most continued kind. In all these
cases, the fever has its paroxysm protracted longer
than usual, before it changes into a type of more fre-
quent repetition.

32. From all this a presumption arises, that every
fever consists of repeated paroxysms, differing from
others chiefly in the circumstances and repetition of the
paroxysms; and therefore, that it was allowable for us
to take the paroxysm of a pure intermittent as an ex-
ample and model of the whole,

PRACTICE OF PHYSIC. 99

CHAPTER II*

OF THE PROXIMATE CAUSE OF FEVER.

33. THE proximate cause of fever seems hitherto to
have eluded the research of physicians; and I shall not

* In this and the following chapter, which treats of the " difference of fe-
vers and its causes," our author has placed before us as curious a specimen
of the " frost-work of fancy" as is any where to be found in the records of
medicine- He has, with great labour, and not a little ingenuity, piled one
hypothesis on another, each alike incapable of supporting or being support-
ed, until he has erected a monument of conjecture altogether commensurate
with his own greatness. It is thus that illustrious men oftentimes distin-
guish themselves not more by their virtues and excellencies, than by their
errors and faults.

In all our reading we do not recollect ever to have met with a more vi-
.sionary production, or a more inconclusive attempt to give shape and stabi-
lity to any opinion, than that of Dr Cullen to establish here his theory of
fever. Throughout the whole course of his affected reasoning, there is
nothing presented to us but one unqualified assumption after another, until,
at the end, we find that every thing has been assumed and nothing confirm-
ed — every thing asserted and nothing proved. The worst and most dan-
gerous feature of the doctrine is, that there is thrown around it an air of
plausibility and candour, exceedingly seductive of the youthful mind. In a
man of years and experience, extensive learning and philosophical research,
we deem it scarcely consistent with intellectual honesty and moral recti-
tude, thus to palm on unsuspecting youth, and that portion of feeble minded
adults, who read only to believe and adopt, a tissue of errors, in which it is
almost impossible he could himself have believed — which he must, at least,
have considered in the nature of postulata, that did not promise to be readily
converted into demo> strated truths.

Independently of the error which such hypothetical structures actually
inculcate, they are, when reared by high authority, professional articles of
pernicious tendency. Their example is contagious, and renders the pro-
cess of fancying, instead of experimenting and observing, fashionable in medi-
cine. They give sanction and encouragement to those indolent inquirers,
whose practice it is to substitute conjecture for observation and speculation
for research ; and thus become the cause of a wide spreading evil.

Had we leisure to engage in it, a fair analysis of our author's theory
would afford ample testimony that we do not speak of it in terms of exag-
geration. H s atony and diminished enerq-y of the bruin, his sedative causes of
fever, and all his operations of the vis medicatrix naturx, as he employs them^

100 PRACTICE OF PHYSIC.

pretend to ascertain it in a manner that may remove
every difficulty; but I shall endeavour to make an ap-

would appear to be as absolute fictions as any thing that gives colouring to
the pages of romance.

We think there cannot be, in nature, a more preposterous hypothesis,
than that which attributes to the influence of a sedative agent— if the expres-
sion be, admissible— an augmentation of excitement in living matter— which
derives an increase of action, whether healthy or diseased, from that which,
in its nature, is acknowledged to be calculated only to diminish action; and
which receives even its name from its supposed power to effect such dimi-
nution. When medical writers shall have learnt to deal more in matter,
and less in mere words, unsanctioned by reason, we feel persuaded that the
term sedative will be erased from the nomenclature of materia medica.
Strictly and philosophically speaking, we consider it as nothing but an
empty sound.

If the term, even in common acceptation, possess any meaning at all, a se-
dative is that, which, by diminishing or removing existing impression, di-
minishes or suspends existing action. If the impression be not removed, it
is a law of nature that the action will continue. But how can a substance or
agent remove from living matter an impression already in existence, or sus-
pend or alter action already going forward, otherwise than by substituting
an impression and a mode of action of its own ? Such a process is impossi-
ble A stimulant impression inducing action is a reality, and cannot be re-
moved or in any way affected by that which is not a reality. If a reputed
sedative be a reality, it must, when applied to living matter, act ; and if
it act, it must make an impression : this very action and impression, there-
fore, pronounce it to be a sedative only in name, not in fact : to be capable
of acting and impressing, it must be a stimulant ; impression being nothing
but another name for stimulating action. •

For the more clear and satisfactory illustration of our subject, we shall in-
stitute a comparison with certain phenomena in nature which are perfectly
understood. Living action, the result of stimulation, may be aptly enough
compared to a stream of water, or a moving body : it possesses a degree of
impetus or force. To arrest or alter the course of a flowing stream or a
bodv in motion, force must be opposed to it. A mere negative oppos tion,
i. e. opposition without force, will be found insufficient. Such precisely is
the case in relation to living action. It is sent forward by one impression,
and can be stopt or altered only by another. A substance incapable of mak-
ing an impression cannot effect it.

Again : the Will is put in action only by motive, and nothing but another
motive can alter or suspend its action. That which is incapable of acing
as a motive — being to it a nonentity — can have no influence on it. The
same thing is true of animal action arising from stimulus: nothing short
of stimulus can slop it. That which has no stimulating power stands in the
same relation to it as if it had no existence. But in a case that is so plain,
we deem it superfluous to multiply words. To attribute to reputed sedatives
♦he power of altering vital action in any other way than by means of iin-

PRACTICE OF PHYSIC. 101

proach towards it, and such as, I hope, may be of use
in conducting the practice in this disease: while at the

pression, would be to assert the existence of an effect without a cause. In
the strict sense of the term, a sedative is known only in the language of the
schools.

To remove as far as practicable every difficulty and objection that might
be thrown in our way, we shall dwell a little longer on this subject, which
we deem not only interesting in itself, but essentially connected with cor-
rect views in medical science

When we consider the human body as divided into several subordinate-
systems or parts, we know that a substance or agent which increases action
in one of these parts, may, at the same time, diminish it in another — in other
words, that the same substance which acts directly as a stimulus to the for-
mer, may be indirectly a sedative to the latter. This sedative effect, how-
ever, does not here arise from a sedative nature in the agent which produces
it ; it results from what Dr Darwin calls, not improperly, the " reverse sym-
pathies" of living matter. The substance is, as to its own qualities, a pure
stimulus, because it augments the action of the part with which it comes in
immediate contact; it becomes a sedative only in consequence of the struc-
ture and associations of the body on which it acts.

A blistering plaster applied to the thorax, in a case of peripneumony, or
to the head, in a case of phrenitis, increases in each case the action of the
external skin ; but diminishes, in the former, the action of the pleura, and,
in the latter, that of the dura mater. No one, however, dreams of bestow-
ing on cantharides the name of a sedative.

If a few grains of tartarized antimony be swallowed, they stimulate the
stomach into violent action ; but reduce very greatly the action of the arte-
ries. Notwithstanding this remote sedative effect, no medical writer of the
present day will venture to call this preparation of antimony any thing but
a stimulus. Its sedative operation arises entirely from the sympathies of
the body on which it acts. The same thing may be said in relation to oxyde
of arsenic and corrosive sublimate. If swallowed in considerable quantities,
they stimulate the stomach to inordinate action ; but diminish, at first, in an
equal degree, the action of the arteries. By no one, however, are they re-
garded in the light of sedatives.

Opium, although acknowledged by all to be the most powerful stimulus,
operates, notwithstanding, as a sedative to the nerves. It is by this secon-
dary mode of action that it relieves pain.

The strongest artificial caustics, and the actual cautery itself, are applied
to the skin to reduce, and do reduce, the action of certain internal parts
when in a state of inflammation. Even these substances, therefore, operate
as sedatives through the medium of sympathy.

Thus might we examine by analysis the whole materia medica, and show
that every article which it contains, may, hy the mode in which it is em-
ployed, be made to produce, on some part of the human body, a sedative
effect ; and yet, that each article in itself is strictly a stimulus, because it

102 PRACTICE OF PHYSIC.

same time I hope to avoid several errors which have
formerly prevailed on this subject.

excites, in every instance, an increase of action on the part to which it 19
proximately applied.

That which produces excitement, say those who have the reputation of
being most deeply versed in this doctrine, is a stimulus. But excitement,
as applied to man, consists in motion, sensation, and thought. Whatever,
therefore, produces, in man, the phenomena of motion, sensation, and
thought, or either of them, is necessarily a stimulus.

Had we leisure to examine cold, on the principles of the doctrine of sti-
mulation contained in this syllogism, we should find it, in its action, to agree
with them most perfectly in every respect. Heat, perhaps, alone excepted,
there does not appear to exist in nature another agent, which surpasses
cold in its manifestation of the characters and effects of a stimulus. It pro-
duces sensation, as the term itself implies; for the sensation of cold is as
familiar an expression as that of heat. It might even, perhaps, be stated as
a question, which of the two sensations is capable of being raised to the
most tormenting height ? intense cold being quite as painful as a severe
burn. If heat be a stimulus to the nerves, therefore, so is cold : for the laws
which govern them and the phenomena they exhibit are precisely alike.
But sensation implies nervous motion. In producing the former, therefore,
cold cannot possibly fail to produce the latter also.

In man, motion and sensation, by a law of our nature, excite attention!
which, being an intellectual operation, is tantamount to thought. Hence it
is plain, that cold is capable of giving rise to the three only modes of ex-
citement that stimuli produce — motion, sensation, and thought. Cold is,
therefore, itself a stimulus.

Like other agents, cold is not capable of producing excitement in every
part of our systems at once. The laws of animal sympathy prevent this.
While it operates as a stimulus on one part or subdivision of our bodies, its
effect on another is that of a sedative.

If water, at the temperature of forty degrees of Fahrenheit, be applied
for a time to the wrists and ankles, it reduces very considerably the force
and frequency of arterial action ; but produces, at the same time, a strong
sensation. While it is a sedative to the arteries, therefore, it cannot be
denied to be a stimulus to the nerves and skin It excites the part with
which it comes in contact. It operates here, in a manner precisely analo-
gous to ipecacuanha, digitalis, tartarized antimony, and many other sub-
stances which we need not enumerate. Those articles, when swallowed in
a sufficient quantity, stimulate the stomach, but, by sympathy, act as a seda-
tive to the arteries. Cold stimulates the skin, but acts as a sedative to the
same parts.

We shall conclude our remarks on cold by observing, that were it practi-
cable for us to pass, in analytical detail, through the whole doctrine respect-
ing that agent, it would be easy to show, that every law, principle and phe-
nomenon of stimulation are as applicable to it, as they are to heat or opium,
cantharides or alkohol. Nor can there be produced a single fact, in rela-

PRACTICE OF PHYSIC. JOS

34. As the hot stage of fever is so constantly pre-
ceded by a cold stage, we presume that the latter is the

tion to the action of cold on living matter, which is not perfectly explicable
on the ground of its being possessed of stimulating powers.

Having declared our disbelief in the existence of any substance or agent
strictly entitled to the denomination of a sedative, it follows, of course, that
we differ from Dr. Cullen, in his opinion respecting the nature of febrile
contagions. We consider these poisons as powerful stimulants. Indeed,
the very idea of a sedative poison involves an inconsistency, which, in our
estimation, nothing can surpass. All poisons act by stimulation ; and those
which do not overwhelm life instantaneously, by a first impression, destroy
it ultimately through the medium of inflammation.

Of febrile contagions, it is much to be regretted, that, philosophically
speaking, we know but little. Among the great variety that is supposed to
exist, there are only two that we have been able to realize, take hold of,
and bring completely to the test of experiment. These are, the contagion
of small pox and the contagion of kine pox. Of those two poisons, the
nature cannot possibly now be a topic of controversy. Their stimulating
qualities are as susceptible of demonstration, and are, indeed, as often de-
monstrated, as any truth in the science of physics. By the puncture of a
lancet, introduce either of them beneath the cuticle, and, in a few hours,
inflammation ensues It is needless to say that this would not be the case,
were they of a sedative nature.

Yet the poison of small pox, when casually introduced into the human
system, produces, oftentimes, as much debility as marks the character of
even typhus gravior, cynanche maligna, or any other febrile disease : and it
seems to be in consequence of their debilitating effects, that Dr. Cullen
and other writers have bestowed on contagions the name of sedatives.

These poisons, say those writers, when acting on the body of man, dimi-
nish its powers: but the diminishing of power is a sedative process; the
substances in question are consequently sedatives.

This syllogism, although plausible in appearance, is utterly fallacious. By
a similar mode of reasoning, there is nothing capable of seriously injuring
the human body, that may not be clearly proved to be a sedative.

Thus, for example, arsenic and corrosive sublimate, vitriolated copper
and opium, if taken in excessive quantities, produce extreme debility in
the system. If a pint of alkohol be swallowed at a draught, it greatly debi-
litates, and is, perhaps, even productive of sudden death. Does it, there-
fore, follow that these articles are sedatives ? It certainly doe9 not : no phy-
sician of the present day will venture to call them so : they are acknow-
ledged to be stimulants of the highest order.

A severe blow on the head, a deep and extensive burn on the surface of
the body, and the passage of a bullet or a bayonet through the Jungs or the
stomach, are all productive of great debility : yet no one will contend that
wounds, burns, and blows are sedative agents.

The production of debility by a stimulating agent is a phenomenon easily
explained.

104 PRACTICE OF PHYSIC.

cause of the former; and therefore that the cause of the
cold stage is the cause of all that follows in the course
of the paroxysm. — See Boerh. Aph. 1756.

The human body is a compound of sympathizing organs. Its power de-
pends on the harmonious action of all its parts. The healthy condition of
each important subdivision is necessary to the strength of the entire ma-
chine. Of these organs or subdivisions the stomach must be regarded as one
of the principal. Whatever materially injures the stomach, therefore, im-
pairs the force of the whole system.

Of stimuli, some are deleterious in their own nature, and others are ren-
dered so by an excess in quantity. Of the former description are arsenic
and corrosive sublimate ; and of the latter, wine and ardent spirits.

W r hen by either of these articles the stomach is too powerfully acted on,
its healthful harmony with the other parts of the body is, for the time, de-
stroyed. It no longer extends to them its natural and invigorating sympa-
thies, nor imparts to them the strength they have usually derived from it.
However much, therefore, its own action may be increased by means of
the stimulus within it, the action of the system at large is greatly dimi-
nished. The general effect is that of debility ; not because a real sedative
is in operation on the system, but because the functions and strengthening
associations of the stomach are materially impaired by the action of stimu-
lus. That organ, which is a governing one, and, in relation to its associates,
resembles the sun in the solar system, no longer performs its destined part.
The others, being deprived of the chief impu'se which awakened and put
them in motion, and of the power of attraction which drew together their
living energies, lose, in a great measure, their efficiency and force. The cen-
tre of the confederacy being disordered, sickness and debility cannot fail to
pervade the whole : the keystone of the arch being shattered and loosened,
the entire structure is weakened, and in danger of falling to pieces.

The same thing is true, to a certain extent, if, by means of a stimulus, a
material injury be done to the brain, the lungs, the heart, the intestines, the
kidneys, the liver, the testicles, or any other important organ of the body.
A general sedative effect ensues : the strength of the system is necessarily
impaired, in a degree corresponding to the weight of the suffering organ
and the injury it has sustained.

As we shall have occasion, hereafter, to express our sentiments some-
what fully on the subject of febrile contagions, we shall, at present, only
add, that we believe these poisons to be considered by physicians as much
more numerous than they really are.

With Dr. Cullen's theory of fever we have expressed ourselves dissatis-
fied. Viewed as a whole, we consider it an unqualified tissue of error,
equalled only by that which a late distinguished American teacher so indus-
triously laboured to erect on its ruins.

With the Edinburgh professor we confidently believe in the existence of a
ww medicatrix naturct — an active power, whose office is to preserve nnd re-
Store the health of the body. The operations of this power are conclu-

PRACTICE OF PHYSIC. 105

35. To discover the cause of the cold stage of fe-
vers, we may observe, that it is always preceded by

sively manifested in the healing of wounds, the knitting of fractured bones,
the ejection of deleterious substances from the stomach, and many other
processes which we cannot now enumerate. Were it not for its action and
aid, recovery from disease would be absolutely impossible. Man's first ma-
lady would necessarily be his last, by a law of nature which human exer-
tions would be unable to countervail.

No enlightened and honest physician will venture to say, that, by his re-
medies alone, he ever gave health to a single individual. The utmost of his ser-
vices has been, to -weaken disease, leaving to nature the final and complete
restoration of health.

When the malady is slight — a moderate fever, for example, or a common
catarrhal affection — nature, unassisted, is perfectly competent to the cura-
tive process. Hence, in such cases, medical aid is rarely solicited. In com-
mon language, the disease is said to get well of itself. This, however, is
not the case. Medical science disavows the fact. As no malady can occur
without the agency of a morbific cause, neither can it be removed without
the aid of a curative one. But where no medicines are administered, the
only curative cause that can be supposed to be in operation is necessarily
the vis medicatrix natural.

In diseases so violent as to call for remedies, all that these remedies can
effect is, so far to weaken morbid action, as to render it manageable by the
powers of nature. A powerful malady is converted into a weak one, and
nature then completes its removal. To the truth of these remarks there is
no exception. A physician can no more, by his own exertions, cure a dis-
ease, than a surgeon can an incised wound. The latter places the separated
parts in contact, retains them there by a suitable apparatus, recommends to
his patient the necessary regimen, and leaves to natilre the curative process.
Nor is it in the power of the former to proceed further. If he be perfectly
versed in his profession, he reduces the system of his patient to the proper
state of action with regard to force, enjoins rest, prescribes the regimen
which the case demands, and, for a final cure, trusts alone to the vis medi-
catrix. Hence it requires in a practitioner as much skill and experience to
know when to withhold his remedies, as when to administer them.

Although, for the foregoing reasons, we believe in the existence of a heal-
ing power in nature, we are by no means satisfied with the exposition of its
operations, which Dr Cullen has attempted, in his theory of fever. His
reasoning on the subject is forced and artificial, unsatisfactory and confused.

For the principles of what we consider a correct theorv of fever, we can-
not do better than refer our readers to Darwin's Zoonomia. We be! eve,
with the very acute and distinguished author of that work, that fever is
essentially a disease of association — that it is formed alone through the me-
dium of sympathy. It begins, as we have said, in another place, at a point,
and spreads throughout the system, instituting a chain of diseased associated
motions, consisting of as many links as there are parts or subdivisions of the
body affected.

VOL. I. O

106 PRACTICE OF PHYSIC.

strong marks of a general debility prevailing in the sys-
tem. The smallness and weakness of the pulse, the

Dr. Clutterbuck is also an advocate fbr the doctrine of the original loca-
lity of fever. But he places the primary irritation in the brain. In this he is
mistaken, as it shall be, presently, our business to endeavour to prove.

To illustrate a little further. We are persuaded that most febrile diseases
have thiir origin or first topical affection in the stomach, the skin, or that
portion of the Schneiderian membrane which lines the fauces, the trachea,
and the bronchia. We feel satisfied that all malignant fevers, in particular,
have their seat in the stomach. In the blood-vessels, the nerves, the lym-
phatics, the brain, orthe glands, they cannot originate, for the strongest of
reasons : to these parts the causes producing them cannot have primary
access.

Having commenced in its customary seat, the stomach, fever proceeds to
invade, by sympathy, the nerves, the skin, the blood-vessels, the lymphatics,
the glands, and the brain, until its chain of associated diseased action em-
braces, at length, the entire system. Commencing in the skin, as some,
perhaps, of the phlegmasia and hemorrhagic do, it, on the same principles,
pursues a similar march, until it has formed a chain of equal extent. On no
other ground of explanation than this, do we consider fever as an intelligible
disease.

Although we consider Dr. Darwin correct in his general principles and
outline of fever, he has attempted to introduce into his exposition so much
of the minutiae of associated action, as to render it, to us, in some parts, unin-
telligible. Much interesting and important information, however, may be
derived from his writings on this subject.

We observe that, in the medical school of New York, there is on foot,
under the auspices of our able and very distinguished friend, Dr. Hosack, an
attempt to revive no inconsiderable portion of the long-exploded doctrines
of the Humoral Pathology. A full and lucid exposition of what we believe
to be the professor's views on this subject may be seen in Dr. Dyckman's
learned and well written Inaugural Dissertation, for the year 1814

Against this attempt we would be understood as bearing, most delibe-
rate!}, our decided testimony. Sound pathology consists in the history and
philosophy of the diseased action of our solids, not of the vitiated condi-
tion of our fluids. Even admitting that the humours of the body do be-
come somewhat changed from their natural and healthy condition, it is as a
consequence, not an original cause of disease — the result, not the origin of
morbid action.

Although the New York school does not appear to be an advocate for
the real putridity of the blood during life, but contents itself with maintain-
ing its putrescency only ; it asserts its full and confident belief, not in the
mere vitiation of that fluid by means of the severaJ morbific poisons, but in
its actual assimilation to their nature and qualities. According to the tenets
of that seat of science, the matter of small pox produces in the blood a va-
riolous taint, the matter of kine pox a vaccine taint, and the matter of mea-
sles a morbillous taint; each poison assimilating that fluid to its own charac-

PRACTICE OF PHYSIC, 107

paleness and coldness of the extreme parts, with the
shrinking of the whole body, sufficiently show that the

ter, and rendering it capable, by inoculation, of communicating the disease
to which the poison appertains.

This doctrine is signally erroneous. It is contrary alike to the issue of ex-
perience, and the principles of legitimate and sound physiology.

On the ground of experiments made by ourselves, we assert that the
blood of persons affected by small pox, kine pox, and measles, will not com-
municate those diseases. We even avow our disbelief in the communicabi-
lity of measles by any mode of inoculation. We have endeavoured to com-
municate it by every way we could devise, inserting under the cuticle of
the person inoculated, the blood, the tears, the mucus secreted by the
Schneiderian menfbrane, and even the matter of eruption of the individual
diseased, but have always failed.

If the proper precautions be observed in the drawing of blood, and in
the performance of the act of inoculation, we repeat, that that fluid cannot
be rendered instrumental in the propagation of any contagious disease-

In a contagious fever — suppose it to be a case of casual small pox — through
what channels can the poison gain admission to the blood ? We answer,
through two only — the lacteals or cutaneous lymphatics. Nature has pro-
vided no other ; nor can art form one.

To physiologists, the nice appetency or power of selection of these organs
is well known. They admit into their mouths, and convey to the thoracic
duct, no admixture of heterogeneous materials. To nothing will they grant
admission and conveyance, until it be digested and assimilated to an uniform
mass. If they take up bone or muscle, fat or glandular matter, they receive
neither of them in its formal character. Each must undergo a preparatory
process, by which it is divested of its specific properties, and made to as-
sume the character of chyle or lymph.

Such must be also the case in relation to contagion. If it be taken up by
the absorbents at all, it cannot enter them in its formal state. They do not
receive it while armed in all its deleterious qualities. It must have laid
these aside, and become one of the component parts of lymph or chyle.
Thus changed, it is no longer contagion, and can produce no other than a
common effect on the blood, tending to augment, not to vitiate it.

But the truth is, that no febrile poison ever enters the absorbents in any
form Its very nature as a poison prevents this. It attaches itself to some
spot in the system, and produces there a peculiar irritation, which is propa-
gated by sympathy from one part to another, until the whole experiences
its deleterious influence. Its action is therefore confined to the solids alone,
the fluids participating in none of its qualities.

Whether we attempt an investigation of the modus operandi of conta-
gions, in the production of fevers, or of remedies, in their cure, we must
confine our attention to the solids of the body. Be it of a nature deleteri-
ous or sanative, it is through them alone that the work is effected. Our
present views of physiology lead to a disbelief in the medication, no less
than in the contamination, of the human fluids. Whatever enters the lac

108 PRACTICE OF PHYSIC.

action of the heart and larger arteries is, tor the time,
extremely weakened. Together with this, the languor,

teals enters them as chyle, and, as such, is intended for nutriment ; not to
communicate to the blood either medicinal or morbific qualities.

The facts, that madder passes through the blood, and tinges the bones of
animals red ; that, some time after the articles have been themselves swal-
lowed, the odour of asparagus, spirits of turpentine, and garlic is discover-
able in the urine and matter of perspiration ; that the taste of certain vege-
tables which have been eaten becomes perceptible in the milk of females ;
and that in the blood of a person long accustomed to the use of soda, as a-
medicine, a great superabundance of that substance has been found — these
facts, we say, with various others somewhat similar, that might be easily
cited, furnish no argument of weight against our opinion.

That the articles just mentioned have made their way into the blood, will
not be denied. But they entered it, not in a crude and formal state, but as
a digested and assimilated portion of chyle. Hence they became a com-
ponent part of the blood itself, perfectly homogeneous with its other parts.
But when that fluid had lost its vitality, and become decomposed in the
crucible of the chemist, the soda, which it contained in substance, not in
form, was immediately revived. It is thus that both soda and potash are
formed, by combustion, from plants, which contain nothing but the raw ma-
terials out of which these articles are made. Without combustion they
. cannot be obtained, although substantially present in the plant.

It is for a similar reason that the smell and taste of certain alimentary
and medicinal matters are perceptible in the secretions and excretions of
of the body. These qualities are not found in the blood, that fluid retaining
its usual taste and odour. They are only revived in the fluids secreted
from it, by means of the chemical affinities, which, being now permitted to
act, uncontrolled by the powers of assimilation, recompose the peculiar
forms of matter, wherein the taste and smell of the plants existed. In the
urine of a person that has eaten asparagus, the smell of that plant is revived
by chemical affinity; although it is not present in the blood whence the
urine is prepared ; and, in the milk of a cow that has eaten garlic, both the
taste and smell of that vegetable are chemically revived, while the blood
of the animal is entirely exempt from them.

A very strong ground of belief that no crude unassimilated materials are
ever, during life, admitted into the mass of blood, is, that if such articles
be introduced into the blood-vessels, even in the greatest state of dilution,
immediate and great suffering, if not actual death, is the inevitable conse-
quence.

In treating of the causes of fevers, we feel persuaded that Dr. Cullen has
fallen into a common error, attributing to contagion much more than justly
belongs to it. Strictly speaking, the number of contagious febrile diseases
is very limited. In our estimation, the order Febres of our author does
not contain one. We believe they are all included under that of Exanthe-
mata. Belonging to this order, the number of diseases unequivocally con-

PRACTICE OF PHYSIC. 109

inactivity, and debility of the animal motions, the im-
perfect sensations, the feeling of cold, while the body

tagious does not exceed four, — small pox, kine pox, chicken pox, and mea-
sles. Even of the two latter complaints, the contagion is by some physi-
cians considered as doubtful.

All febrile poisons are not contagions. Those resulting from putrefac-
tion, whether of animal or vegetable substances, ought not to be so deno-
minated. We have already mentioned, and beg leave to repeat, that-conta-
gion is a secreted poison — the result of morbid animal action. By way of
distinction, febrile poisons arising from putrefaction have been denominated
infections. By the late Dr. Miller of New York, terms were applied to
these two species of morbific causes, which ought not to be rejected without
due consideration. If we are not mistaken, they serve the purpose of accu-
rate discrimination better than any others that have been heretofore in-
vented.

To febrile poisons resulting from putrefaction, that writer gave the name
Koino — from the Greek word kwos, which signifies common— pointing out the
extent and community of their origin ; thus making the compound term,
Koino-miasmata, common febrile poisons. On those arising from diseased
secretory action he bestowed the epithet Idio — from the Greek word af/oc,
peculiar or specific — expressing thereby, at once, the peculiarity of their
origin, and their specific character ; and designating them by the compound
term Idio miasmata, specific febrile poisons.

Contagion being the offspring of morbid glandular action, to render its
existence certain, the glands which secrete it must have themselves an ex-
istence. But of their existence we cannot be certain, unless they be visi-
ble .- and how very few are the febrile diseases that are unequivocally
marked by morbid glands ! Small pox, kine pox, and chicken pox, consti-
tute, perhaps, the whole amount. In measles and the other exanthemata,
the existence of such bodies is far from being certain. Nor is the case dif-
ferent with regard to typhus, synochus and dysentery. In these diseases no
morbid glands, nor any thing tantamount to them, ever appear. Hence one
cause of denying them a contagious character.

There does not, perhaps, exist in medical science a point of doctrine that
stands on so unstable a foundation, and is, at the same time, so loosely
constructed, as that which treats of febrile contagion. On other points we
require, for our satisfaction, experimental demonstration s here we rest con-
tented with the most equivocal appearances — such as scarcely lay a founda-
tion for the feeblest probability.

A. disease, marked by a few unusual symptoms, attacks at once, or in suc-
cession, a family, a neighbourhood, or an entire community. This is suffi-
cient ; nothing further respecting it is sought for. .No inquiry is instituted
as to its real nature. The mere circumstance of numbers suffering from it is
deemed sufficient to fix its character. It is without hesitation pronounced
to be contagious. Yet there does not exist on the persons of those who are
subject to it., a single glandular body or character by which a morbid poison
could be secreted. No change of moment has taken place in them except

110 PRACTICE OF PHYSIC.

is truly warm, and some other symptoms, all show that
the energy of the brain is, on this occasion, greatly

what is common to febrile diseases. Neither in their secretions nor excre-
tions does any thing unusual or suspicious appear.

In a case like this, there is no solid ground for a belief in contagion. A
disease spreads and becomes general in a neighbourhood from sundry other
causes — bad water, damaged provisions ; but more especially from a vitiated
atmosphere. It is well known that, in consequence of atmospheric influ-
ence, even peripneumony, rheumatism, angina inflammatoria, croup, and
other diseases never suspected of contagion, assume, at times, an epidemic
prevalence — they run through families and neighbourhoods, towns, and
cities.

We have in another place observed, that contagion, strictly so called, is a
specific substance, else it would not be contagion — it would not, as it does,
possess powers of self propagation. These powers, which bestow on it its
character, it exercises absolutely, on all occasions, and in a specific and uni-
form manner, independently of season, situation, temperature, and all other
adventitious circumstances. It is a positive virus, and poisons certainly,
from its own qualities, whenever it is applied to a susceptible subject. This
it does as well in the rigours of January, as in the heats of August ; in an
open, no less than in a confined situation ; and in the pure and salubrious
air of the country, as readily as in the vitiated atmosphere of a large city.
Such is the case with the contagions of small pox, kine pox, and lifes vene-
rea. Seasons, situations, and qualities of the atmosphere are totally indif-
ferent to these poisons. They act from their own inherent powers, with as
much certainty as opium or arsenic, corrosive sublimate, or any other dele-
terious article.

When we find a disease, therefore, that is either of a local or a temporary
character— one that prevails and spreads during the summer and autumn,
and in the crowded streets and alleys of a large city, but disappears on the
occurrence of cold weather, and can never be propagated in open and freely
ventilated situations in the country — or another which prevails during cold
weather, and in towns, hamlets, and country situations, but ceases on the
approach of summer, and is scarcely known in large cities. — When we find
febrile diseases of this description, we should be cautious in attributing to
them the qualities of contagion. We may feel confident, indeed, that their
prevalence arises, not from that, but from other causes Hence, both typhus
fever, yellow fever, and even pestis vera, want characteristics sufficient to
prove them to he contagious diseases. These complaints are known to be
circumscribed in their prevalence, both as to place and time. Pestilence
and yellow fever spread only during warm weather, and in a vitiated atmo-
sphere ; typhus fever requires also a vitiated atmosphere, but prevails most
during cool weather. The miasmata of the former become sufficiently abun-
dant to contaminate the air of a whole city; those of the latter can seldom
do more than vitiate that of a single.building; or perhaps only of a single
apartment. Perfect atmospheric purity is as fatal to them all, as an entire
want of food is to animal life— and for the same reason -, it deprives them of

PRACTICE QF PHYSIC. HI

weakened; and I presume, that as the weakness of the
action of the heart can hardly be imputed to any other

the aliment necessary to their existence. These complaints have no power
to form, by disordered vascular action, a contagion sufficient for their own
propagation : unless, therefore, the poison be otherwise produced, it fails,
and their course is necessarily arrested.

The accounts we have in print relative to inoculation for the plague, are
entitled to no regard. The matter used for the purpose was taken from
bubos or carbuncles. But these are not essential murks of the disease. In
a very great majority of the cases of plague there are neither carbuncles
nor suppurated bubos.

In these there can, of course, be no contagion. There must be, therefore,
two species of the same complaint; one communicable and the other not.
Such a supposition, however, is not admissible : it is even absurd. Plague
is either contagious, in its nature, and, therefore, in every instance ; or it is
not contagious at all.

Again : we have no knowledge of the proper method of inoculating for
plague. All poisons do not take effect on every part of the body. Arsenic
and corrosive sublimate, introduced into a small wound in the skin, produce
but little inconvenience. Brought into contact with the stomach, they are
active and dangerous The reverse is true with regard to the poison of the
viper and the rattlesnake. Introduced into a wound, it is highly deleteri-
ous; whereas it may be swallowed with perfect impunity.

Something similar may be true with regard to pestis vera, even admitting
the disease to be contagious. A puncture in the skin may not be the pro-
per place for the insertion of the poison. The virus may be inefficient
there, although active elsewhere. To render it effective, it may be requi-
site, perhaps, to bring it into contact with the stomach, or some part of the
Schneiderian membrane. Possibly a similar mistake, as to the proper place
of insertion, may be the reason why all attempts to inoculate for measles
have failed.

Further : in the very few cases wherein inoculation is said to have pro-
duced the plague, we know nothing of the progress or particulars of the
operation. We are simply told, that persons who had been inoculated were
attacked by the disease ; but are left at an entire loss as to the source
whence it was derived — inoculation or casual infection Did the envenomed
puncture inflame and pass through such a marked and regular series of
stages, as to appear manifestly to be the cause of the disease ? or did the com-
plaint succeed the inoculation without the occurrence of any such pheno-
mena ? Did the period of time that elapsed, from the operation to the attack,
justify the belief that they stood related to each other as cause and effect ?
These are points respecting which we are totally uninformed Yet a know-
ledge of them is essential to our understanding of the cases to which they
relate.

For the reasons herein given we feel persuaded that the number of truly
contagious diseases is much more limited than it is generally supposed to
be.

112 PRACTICE OF PHYSIC.

cause, this weakness also is a proof of the diminished
energy of the brain.

36. I shall hereafter endeavour to show, that the
most noted of the remote causes of fever, as contagion,
miasmata, cold and fear, are of a sedative nature; and
therefore render it probable that a debility is induced.
Likewise, when the paroxysms of a fever have ceased
to be repeated, they may again be renewed, and are
most commonly renewed by the application of debilitat-
ing powers. And further, the debility which subsists
in the animal motions and other functions through the
whole of fever, renders it pretty certain that sedative
or debilitating powers have been applied to the body.

37. It is therefore evident, that there are three states
which always take place in fever: a state of debility, a
state of cold, and a state of heat; and as these three
states regularly and constantly succeed each other in
the order we have mentioned them, it is presumed that
they are in the series of cause and effect with respect
to one another. This we hold as matter of fact, even
although we should not be able to explain in what man-
ner, or by what mechanical means these states several-
ly produce each other.

38. How the state of debility produces some of the
symptoms of the cold stage, may perhaps be readily
explained; but how it produces all of them, I cannot
explain otherwise than by referring the matter to a
general law of the animal economy, whereby it happens,
that powers which have a tendency to hurt and destroy
the system, often excite such emotions as are suited to
obviate the effects of the noxious power. This is the
vis medic atrix nature, so famous in the schools of
physic; and it seems probable, that many of the motions
excited in fever are the effects of this power.

39. That the increased action of the heart and arte-

PRACTICE OF PHYSIC. 113

ries, which takes place in the hot stage of fevers, is to
be considered as an effort of the vis medicatrix natures,
has been long a common opinion among physicians;
and I am disposed to assert, that some part of the cold
stage may be imputed to the same power. I judge so,
because the cold stage appears to be universally a means
of producing the hot; because cold, externally applied,
has very often similar effects; and more certainly still,
because it seems to be in proportion to the degree of
tremor in the cold stage, that the hot stage proceeds
more or less quickly to a termination of the paroxysm,
and to a more complete solution and longer intermis-
sion. See SO.

40. It is to be particularly observed, that during the
cold ^tage of fever, there seems to be a spasm induced
every where on the extremities of the arteries, and more
especially of those upon the surface of the body. This
appears from the suppression of all excretions, and from
the shrinking of the external parts: and although this
may perhaps be imputed in part to the weaker action of
the heart in propelling the blood- into the extreme ves-
sels; yet, as these symptoms often continue after the
action of the heart is restored, there is reason to believe
that a spasmodic constriction has taken place; that it
subsists for some time, and supports the hot stage; for
this stage ceases with the flowing of the sweat, and the
return of other excretions, which are marks of the re-
laxation of vessels formerly constricted. Hoffman. Med.
rat. System. Tom. 4. P. 1. Sect. 1. Cap. 1. art. 4.

41. The idea of fever, then, may be that a spasm of
the extreme vessels, however induced, proves an irrita-
tion to the heart and arteries, and that this continues till
the spasm is relaxed or overcome. There are many
appearances which support this opinion; and there is
little doubt that a spasm does take place, which proves

vol. i. p

114 PRACTICE OF PHYSIC

an irritation to the heart, and therefore may be con-
sidered as a principal part in the proximate cause of
fever. It will still, however, remain a question, what
is the cause of this spasm; whether it be directly pro-
duced by the remote cause of fever, or if it be only a
part of the operation of the vis medicatrix natnrce.

42. I am disposed to be of the latter opinion, because
in the first place, while it remains still certain that a
debility lays the foundation of fever, it is not obvious in
what manner the debility produces the spasm, and what
seems to be its effect, the increased action of the heart
and arteries; and secondly, because, in almost all the
cases, in which an effort is made by the vis medicatrix
naturae, a cold fit and a spasm of the extreme vessels
are almost always the beginnings of such an effort. See
Gaub. Pathol. Medicin. art. 750.

43. It is therefore presumed, that such a cold fit and
spasm, at the beginning of fever, is a part of the opera-
tion of the vis medicatrix; but, at the same time, it
seems to me probable, that during the whole course of
the fever, there is an atony subsisting in the extreme
vessels, and that the relaxation of the spasm requires
the restoring of the tone and action of these.

44. This it may be difficult to explain; but I think it
may be ascertained as a fact, by the consideration of the
symptoms which take place, with respect to the func-
tions of the stomach in fevers, such as the anorexia
nausea, and vomiting. (14.)

From many circumstances it is sufficiently certain,
that there is a consent between the stomach and the
surface of the body: and in all cases of the consent of
distant parts, it is presumed to be by the connection of
the ervous system, and that the consent which appears
between the sentient and moving fibres of the one
part with those of the other, is such, that a certain con-

PRACTICE OF PHYSIC. 115

dition prevailing in the one part, occasions a similar
condition in the other.

In the case of the stomach and surface of the body,
the consent particularly appears by the connection which
is observed between the state of the perspiration, and
the state of the appetite in healthy persons; and if it may
be presumed that the appetite depends upon the state
of tone in the muscular fibres of the stomach, it will
follow, that the connection of appetite and perspiration
depends upon a consent between the muscular fibres of
the stomach, and the muscular fibres of the extreme
vessels, or of the organ of perspiration, on the surface
of the body.

It is further in proof of the connection between the
appetite and perspiration, and at the same time of the
circumstances on which it depends, that cold applied to
the surface of the body, when it does not stop perspira-
tion, but proves a stimulus to it, is always a powerful
means of exciting appetite.

Having thus established the connection or consent
mentioned, we argue, that as the symptoms of anorexia,
nausea, and vomiting, in many cases, manifestly depend
upon a state of debility or loss of tone in the muscular
fibres of the stomach; so it may be presumed, that these
symptoms in the beginning of fever, depend upon an
atony communicated to the muscular fibres of the
stomach, from the muscular fibres of the extreme vessels
on the surface of the body.

That the debility of the stomach which produces
vomiting in the beginning of fevers, actually depends
upon an atony of the extreme vessels on the surface of
the body, appears particularly from a fact observed by
Dr. Sydenham. In the attack of the plague, a vomit-
ing happens, which prevents any medicine from remain-
ing on the stomach; and Dr. Sydenham tells us, that

110 PRACTICE OF PHYSIC,

in such cases he could not overcome this vomiting but
by external means applied to produce a sweat; that is,
to excite the action of the vessels on the surface of the
body.

The same connection between the state of the stomach
and that of the extreme vessels on the surface of the
body, appears from this also, that the vomiting, which
so frequently happens in the cold stage of fevers, com-
monly ceases upon the coming on of the hot, and very
certainly upon any sweat's coming out, (14.) It is, indeed,
probable, that the vomiting in the cold stage of fevers,
is one of the means employed by nature for restoring
the determination to the surface of the body; and it is a
circumstance affording proof, both of this, and of the
general connection between the stomach and surface of
the body, that emetics thrown into the stomach, and
operating there, in the time of the cold stage, commonly
put an end to it, and bring on the hot stage.

It also affords a proof of the same connection, that
cold water, taken into the stomach, produces an in-
crease of heat on the surface of the body, and is very
often a convenient and effectual means of producing
sweat.

From the whole we have now said on this subject, I
think it is sufficiently probable, that the symptoms of
anorexia, nausea, and vomiting, depend upon, and are
a proof of, an atony subsisting in the extreme vessels on
the surface of the body; and that this atony therefore,
now ascertained as a matter of fact, may be considered
as a principal circumstance in the proximate cause of
fever.

45. This atony we suppose to depend upon a diminu-
tion of the energy of the brain; and that this diminution
takes place in fevers, we conclude, not only from the
debility prevailing in so many functions of the body,

PRACTICE OF PHYSIC. H?

mentioned above, (35.) but particularly from symptoms
which are peculiar to the brain itself. Delirium is a fre-
quent symptom of fever; and as from the physiology
and pathology we learn that this symptom commonly
depends upon some inequality in the excitement of the
brain or intellectual organ; we hence conclude, that, in
fever, it denotes some diminution in the energy of the
brain. Delirium, indeed, seems often to depend upon
an increased impetus of the blood, in the vessels of the
brain, and therefore attends phrenitis. It frequently ap-
pears also in the hot stage of fevers, accompanied with
a headach and throbbing of the temples. But as the im-
petus of the blood in the vessels of the head is often con-
siderably increased by exercise, external heat, passions,
and other causes, without occasioning any delirium; so,
supposing that the same impetus, in the case of fever,
produces delirium, the reason must be, that at the same
time, there is some cause which diminishes the energy
of Ae brain, and prevents a free communication between
the parts concerned in the intellectual functions. Upon
the same principles also, I suppose there is another
species of delirium, depending more entirely on the
diminished energy of the brain, and which may there-
fore arise, when there is no unusual increase of the
impetus of the blood in the vessels of the brain. Such
seems to be the delirium occurring at the beginning of
the cold stage of fevers, or in the hot stage of such
fevers as show strong marks of debility in the whole
system.

46. Upon the whole, our doctrine of fever is expli-
citly this. The remote causes (36.) are certain sedative
powers applied to the nervous system, which diminish-
ing tiie energy of the brain, thereby produce a debility
in the whole of the functions, (35.) and particularly in
the action of the extreme vessels, (43. 44.) Such, how-

118 PRACTICE OF PHYSIC.

ever, is, at the same time, the nature of the animal
economy, (38.) that this debility proves an indirect
stimulus to the sanguiferous system, whence, by the
intervention of the cold stage, and spasm connected
with it, (39. 40.) the action of the heart and larger
arteries is increased, (40.) and continues so (41.) till it
has had the effect of restoring the energy of the brain,
of extending this energy to the extreme vessels, of re-
storing therefore their action, and thereby especially
overcoming the spasm affecting them ; upon the remov-
ing of which, the excretion of sweat, and other marks
of the relaxation of excretories, take place.

47. This doctrine will, as I suppose, serve to explain
not only the nature of fever in general, but also the va-
rious cases of it which occur. Before proceeding, how-
ever, to this, it may be proper to point out the opinions,
and as I apprehend, the mistakes, which have formerly
prevailed on this subject.

48. It has been supposed, that a lentor or viscidity
prevailing in the mass of blood, and stagnating in the
extreme vessels, is the cause of the cold stage of fevers
and its consequences. But there is no evidence of any
such viscidity previously subsisting in the fluids; and as
it is very improbable that such a state of them can be
very quickly produced, so the suddenness with which
paroxysms come on, renders it more likely that the
phenomena depend upon some cause acting upon the
nervous system, or the primary moving powers of the
animal economy. See Van Swieten apud Boerh. Aph.
775.

49. Another opinion, which has been almost univer-
sally received, is, that a noxious matter introduced into,
or generated in, the body, is the proximate cause of
fever; and that the increased action of the heart and
arteries, which forms so great a part of the disease, is

PRACTICE OF PHYSIC. H9

an effort of the vis medicatrix naturce to expel this
morbific matter; and particularly to change or concoct
it, so as to render it either altogether innocent, or at
least, fit for being more easily thrown out of the body.
This doctrine, however, although of as great antiquity
as any of the records of physic now remaining, and
although it has been received by almost every school of
medicine, yet appears to me to rest upon a very uncer-
tain foundation. There are fevers produced by cold,
fear, and other causes, accompanied with all the essen-
tial circumstances of fever, and terminating by sweat;
but, at the same time, without any evidence or suspi-
cion of morbific matter.

There have been fevers suddenly cured by a hagmor-
rhagy, so moderate as could not carry out any consider-
able portion of a matter diffused over the whole mass of
blood; nor can we conceive how the morbific matter
could be collected or determined to pass off by such an
outlet as. in that case is opened.

Even supposing a morbific matter were present, there
is no explanation given, in what manner the concoction
of it is performed ; nor is it shown that any such change
does in fact take place. In certain cases, it is indeed
evident, that a noxious matter is introduced into the
body, and proves the cause of fever; but, even in these
cases, it appears that the noxious matter is thrown out
again, without having suffered any change; that the
fever often terminates before the matter is expelled;
and that, upon many occasions, without waiting the
supposed time of concoction, the fever can be cured,
and that by remedies which do not seem to operate
upon the fluids, or to produce any evacuation.

50. While we thus reason against the notion of fever
being an effort of nature, for concocting and expelling a
morbific matter; I by no means intend to deny that the

120 PRACTICE OF PHYSIC.

cause of fever frequently operates upon the fluids, and
particularly produces a putrescent state of them. I ac-
knowledge that this is frequently the case; but, at the
same time, I maintain, that such a change of the fluids
is not commonly the cause of fever; that very often it is
an effect only; and that there is no reason to believe the
termination of the fever to depend upon the expulsion
of the putrid matter.

51. Another opinion which has prevailed, remains still
to be mentioned. In intermittent fevers, a great quan-
tity of bile is commonly thrown out by vomiting; and
this is so frequently the case, that many have supposed
an unusual quantity of bile, and perhaps a peculiar
quality of it, to be the cause of intermittent fevers.
This, however, does not appear to be well founded.
Vomiting, by whatever means excited, if too often re-
peated, with violent straining, seems to be powerful in
emulging the biliary ducts, and commonly throws out a
great deal of bile. This will happen especially in the
case of intermittent fevers. For, as in the state of
debility and cold stage of these fevers, the blood is not
propelled in the usual quantity into the extreme vessels,
and particularly into those on the surface of the body,
but is accumulated in the vessels of the internal parts,
and particularly in the vena portarum; so this may
occasion a more copious secretion of bile.

These considerations will, in some measure, account
for the appearance of an unusual quantity of bile in in-
termittent fevers; but the circumstance which chiefly
occasions the appearance of bile in these cases, is the
influence of warm climates and seasons. These seldom
fail to produce a state of the human body, in which the
bile is disposed to pass off, by its secretories, in greater
quantity than usual; and perhaps also changed in its
quality, as appears from the disease of cholera, which

PRACTICE OF PHYSIC. 121

so frequently occurs in warm seasons. At the same time,
this disease occurs often without fever; and we shall
hereafter render it sufficiently probable, that inter-
mittent fevers, for the most part, arise from another
cause, that is, from marsh effluvia; while, on the other
hand, there is no evidence of their arising from the state
of the bile alone. The marsh effluvia, however, com-
monly operate most powerfully in the same season that
produces the change and redundance of the bile ; and
therefore considering the vomiting, and other circum-
stances of the intermittent fevers which here concur,
it is not surprising that autumnal intermittents are so
often attended with effusions of bile.

This view of the subject does not lead us to consider
the state of the bile as the cause of intermittents, but
merely as a circumstance accidentally concurring with
them, from the state of the season in which they arise.
What attention this requires in the conduct of the dis-
ease, I shall consider hereafter.

52. From this view of the principal hypotheses which
have hitherto been maintained with respect to the proxi-
mate cause of fever, it will appear, that fevers do not
arise from changes in the state of the fluids; but that,
on the contrary, almost the whole of the phenomena of
fevers lead us to believe, that they chiefly depend upon
changes in the state of the moving powers of the animal
system. Though we should not be able to explain all
the circumstances of the disease, it is at least of some
advantage to be led into the proper train of investiga-
tion. I have attempted to pursue it; and shall now
endeavour to apply the doctrine already delivered,
towards explaining the diversity of fevers.*

* Since finishing our remarks on the subject of sedatives, our attention
has been attracted by the two following paragraphs in the works of Dr.
Ferriar, where he is treating of remedies for the cure of Dropsy.
VOL. I. Q

122 PRACTICE OF PHYSIC

CHAPTER III.
OF THE DIFFERENCE OF FEVERS, AND ITS CAUSES

53. TO ascertain the difference of fevers, I think it
necessary to observe, in the first place, that every fever
of more than one day's duration, consists of repeated,
and in some measure separate paroxysms; and that the

" The effect of fox-glove, in retarding the velocity of the pulse, as a direct
sedative, was too striking to be long overlooked ; and when its application,
to diminish morbid irritation in the vascular system, was once pointed out,
the consequences of the idea were easily comprehended."

"The fact," says he, in a note, referring to the word 'sedative? " is so
decisive, that I do not hesitate to employ this term, notwithstanding the
jargon with which the public has of late years been abused on the subject of
sedatives."

We do not affect to know what precise meaning it was the intention of
our author to affix to the terms "jargon" and "abused „•" but if he meant to
designate by them the practice of imposing on the public by an employ-
ment of words either destitute of a meaning, or fraught with error, then are
they strictly applicable to himself, and those other writers who contend for
the existence of sedatives ; not to the advocates of the opposite doctrine.

Dr. P'erriar pronounces Digitalis to be a direct sedative .• we, on the other
hand, maintain that it is a direct and very powerful stimulant; and, in addition
to what we have already advanced, submit, in support of our opinion, the
following remarks.

Of the immediate action of an article on apart not visible, we can best judge,
by its immediate action on parts that are .- for it is not credible that an agent,
of any description, can radically change its own nature — be a direct sedative
in one instance, and a direct stimulant in another. Let us apply this rule —
to the correctness of which we are not sensible that any exception exists —
to determine the nature and action of Digitalis.

If an incision be made in the hand, or a portion of the skin be abraded
from any part of it, and a strong decoction of digitalis applied to the wound,
or denuded surface, the immediate effect is irritation, smarting, and pain;
which will be ultimately succeeded by active inflammation.

If a similar decoction be dropped into the eye, severe smarting, pain, and
an increased secretion of tears will be the consequence; and, in case the
operation be several times repeated, inflammation will ensue.

A strong decoction of digitalis thrown into the urethra will excite irrita-
tion, and produce a puriform discharge, similar to that of actual gonorrhoea.

The same decoction, placed on the tongue, is exceedingly bitter ant 1
acrid to the taste. It certainly, therefore, stimulates the nerves of the part-

PRACTICE OF PHYSIC. j^S

difference of fevers taken notice of above (from 25. to
30.) appears to consist in the different state of parox-
ysms, and in the different circumstances of their repe-
tition.

54. That fevers generally consist of distinct, and in
some measure separately repeated paroxysms, I have
alleged above to be matter of fact; but I shall here en-
deavour to confirm it, by assigning the cause.

55. In every fever, in which we can distinctly ob-
serve any number of separate paroxysms, we con-
stantly find that each paroxysm is finished in less than

for sensation, of whatever description it may be, is nothing but the result of
nervous stimulation.

If, in these several instances, the volatile spirit of ammonia be used in-
stead of a decoction of digitalis, the result will be the same — the excite-
ment of irritation, pain, and inflammation ; and every one will acknowledge
that such excitement is produced by the stimulating- qualities of the spirit.

Is it true, then, that digitalis can produce, as a sedative, the same effects
which arise from the action of spirit of ammonia as a stimulant? or, that the
former article can act as a direct stimulant to the«ye, the tongue, the urethra,
or a denuded portion of muscle, and yet prove a " direct sedative" to the
stomach and blood-vessels ? Of these questions, we cannot be persuaded,
that any one will venture to maintain the affirmative.

If, in the cases herein cited, spirit of ammonia produce excitement and
inflammation, as a stimulant, digitalis must produce them as a stimulant also:
and if this vegetable production be a stimulus to the eye and the tongue, to
mucous surfaces and denuded flesh, and to every part, indeed, where its ac-
tion can be examined, it follows, as an inference, which nothing, we think,
but the folly or madness of hypothesis will controvert, that, when swallow-
ed, it proves to the stomach a direct stimulus, and reduces the action of the
vascular system through the medium of sympathy.

It is reported, moreover, that in cases of death, after the administration
of large and repeated doses of digitalis, unequivocal marks of inflammation
have been discovered in the stomach. This fact we state on the ground of
report alone, having never ourselves performed a dissection, with a view to
the ascertainment of truth on the subject.

To the several experiments already mentioned, a9 calculated to determine
the nature of the action of digitalis, we might add, that if the powder of the
dried leaves of this plant be taken into the nostrils, it will, like the powder
of tobacco, produce irritation, and, sometimes, sneezing.

Either these facts must be reconciled to the sedative nature of digitalis —
an issue which we think impossible — or the hypothesis be abandoned as
false and untenable.

124, PRACTICE OF PHYSIC.

twenty-four hours; but as I cannot perceive any tiling
in the cause of fevers determining to this, I must pre-
sume it to depend on some general law of the animal
economy. Such a law seems to be that which subjects
the economy, in many respects, to a diurnal revolution.
Whether this depends upon the original conformation
of the body, or upon certain powers constantly applied
to it, and inducing a habit, I cannot positively deter-
mine; but the returns of sleep and watching, of appe-
tites and excretions, and the changes which regularly
occur in the state of the pulse, show sufficiently, that
in the human body a diurnal revolution takes place.

56. It is this diurnal revolution which, I suppose, de-
termines the duration of the paroxysms of fevers; and
the constant and universal limitation of these paroxysms,
(as observed in 55.) while no other cause of it can be
assigned, renders it sufficiently probable, that their dura-
tion depends upon, and is determined by, the revolution
mentioned. And that these paroxysms are connected
with that diurnal revolution, appears further from this,
that though the intervals of paroxysms are different in
different cases, yet the times of the accession of pa-
roxysms are generally fixed to one time of the day; so
that quotidians come on in the morning, tertians at
noon, and quartans in the afternoon.

51. It remains to be remarked, that as quartans and
tertians are apt to become quotidians, these to pass into
the state of remittents, and these last to become con-
tinued; and that, even in the continued form, daily
exacerbations and remissions are generally to be ob-
served; so all this shows so much the power of diurnal
revolution, that when, in certain cases, the daily exacer-
bations and remissions are with difficulty distinguished,
we may still presume, that the general tendency of the
economy prevails, that the disease still consists of re-

PRACTICE OF PHYSIC. \25

peated paroxysms, and, upon the whole, that there is
no such disease as that which the schools have called
a continent fever. I expect that this doctrine will be
confirmed by what I shall say hereafter, concerning
the periodical movements observed in continued fevers.

58. It being thus proved, that every fever of more
than one day's duration, consists of repeated paroxysms;
we, in the next place, remark, that the repetition of pa-
roxysms depends upon the circumstances of the pa-
roxysms which have already taken place. From what
was observed (in 30. and 31.) it appears, that the longer
paroxysms are protracted, they are the sooner repeated;
and therefore, that the cause of the frequent repetition
is to be sought for in the cause of the protraction
of paroxysms.

59. Agreeably to what is laid down in 46. and to the
opinion of most physicians, I suppose, that in every fe-
ver there is a power applied to the body, which has a
tendency to hurt and destroy it, and produces in it cer-
tain motions which deviate from the natural state; and
at the same time, in every fever which has its full
course, I suppose, that in consequence of the constitu-
tion of the animal economy, there are certain motions
excited, which have a tendency to obviate the effects
of the noxious power, or to correct and remove them.
But these kinds of motion are considered as constitut-
ing the disease.

But the former is perhaps strictly the morbid state,
while the latter is to be considered as the operation of
the vis medicatrix naturce of salutary tendency, and
which I shall hereafter call the reaction of the system.

60. Upon the supposition that these two states take
place in every paroxysm of fever, it will appear to be
chiefly in the time of the hot stage that the reaction
operates in removing the morbid state; and therefore as

126 PRACTICE OF PHYSIC.

this operation succeeds more or less quickly, the hot
stage of paroxysms will be shorter or longer. But as
the length of paroxysms depends chiefly upon the dura-
tion of the hot stage, so the longer duration of this
and of paroxysms, must be owing either to the obsti-
nacy of resistance in the morbid state, or to the weak-
ness of the salutary reaction; and it is probable that
sometimes the one, and sometimes the other of these
circumstances takes place.

61. It seems to be only by the state of the spasm,
that we can judge of the resistance of the morbid state
of fever; and with respect to this spasm I observe, that
either the cause exciting it may be different in different
cases ; or, though the cause should be the same in
different persons, the different degree of irritability in
each may give occasion to a greater or lesser degree
of spasm: and. therefore, the reaction in fever being
given, the the continuance of the hot stage, and of the
whole paroxysm, may be longer or shorter, according to
the degree of spasm that has been formed.

62. One cause of the obstinacy of spasm in fevers may
be clearly perceived. - In inflammatory diseases, there
is a diathesis phlogistica prevailing in the body, and this
diathesis we suppose to consist in an increased tone of
the whole arterial system. When, therefore, this dia-
thesis accompanies fever, as it sometimes does, it may
be supposed to give occasion to the febrile spasm's be-
ing formed more strongly, and thereby to produce more
protracted paroxysms. Accordingly we find, that all
inflammatory fevers are of the continued kind; and that
all the causes of the diathesis phlogistica have a ten-
dency to change intermittent into continued fevers.
Continued fevers, then, being often attended with the
diathesis phlogistica, we conclude, th;>t, in many cases,
this is the cause of their continued form.

PRACTICE OF PHYSIC. \%%

65. In many fevers, however, there is no evidence of
any diathesis phlogistica being present, nor of any other
cause of more considerable spasm; and, in such cases,
therefore, we must impute the protraction of paroxysms,
and the continued form of the fever, to the weakness of
reaction. That this cause takes place, we conclude
from hence, that, in many cases of fever, wherein the
separate paroxysms are the longest protracted, and the
most difficultly observed, we find the most considerable
symptoms of a general debility: and therefore, we infer,
that in such cases, the protracted paroxysms, and con-
tinued form, depend upon a weaker reaction; owing
either to the causes of debility applied having been of a
more powerful kind, or from circumstances of the pa-
tient's constitution favouring their operation.

64. Upon these principles we make a step towards
explaining in general, with some probability, the differ-
ence of fevers; but must own, that there is much doubt
and difficulty in applying the doctrine to particular
«ases. It applies tolerably well to explain the different
states of intermittents, as they are more purely such,
or as they approach more and more to the continued
form; but several difficulties still remain with respect to
many circumstances of intermittents; and more still with
respect to the difference of those continued fevers, which
we have distinguished in our Nosology as different from
intermittents, and as more specially entitled to the
appellation of Continued, (see Syn. Nos. Meth. P. V.
Ch. I. Sect. II.) and explained more fully above.

65. From the view given (63. and 64.) of the causes of
the protraction of paroxysms, and therefore of the form
of continued fevers, strictly so called, it seems probable
that the remote causes of these operate by occasioning
either a phlogistic diathesis, or a weaker reaction ;
for we can observe that the most obvious difference of

128 PRACTICE OF PHYSIC.

continued fevers depends upon the prevalence of one
or other of these states.

66. Continued fevers have been accounted of great
diversity; but physicians have not been successful in
marking these differences, or in reducing them to any
general heads. The distinctions made by the ancients
are not well understood; and, so far as either they or
the modern nosologists have distinguished continued fe-
vers by a difference of duration, their distinctions are
not well founded, and do not apply in such a manner as
to be of any use. We think it agreeable to observation,
and to the principles above laid down, (63. 64.) to dis-
tinguish continued fevers according as they show either
an inflammatory irritation or a weaker reaction.

67. This distinction is the same with that of fevers
into the inflammatory and nervous; the distinction
at present most generally received in Britain. To the
first as a genus, I have given the name of Synochus; to
the second, that of Typhus; and little studious whether
these names be authorized by the ancient use of the same
terms, 1 depend upon their being understood by the
characters annexed to them in our Nosology, which I
apprehend to be founded on observation.

68. By these characters I think continued fevers may
in practice be distinguished; and if that be the case, the
principles above laid down will be confirmed.

^9. Besides these differences of continued fever, now
mentioned, I am not certain of having observed any
other that can be considered as fundamental. But the
most common forms of continued fevers, in this climate,
seems to be a combination of these two genera; and I
have therefore given such a genus place in our Noso-
logy, under the title of Synochus. At the same time, I
think that the limits between the Synochus and Typhus
will be with difficulty assigned; and I api disposed to

PRACTICE OF PHYSIC. 129

believe, that the Synochus arises from the same causes
as the Typhus, and is therefore only a variety of it.

70. The Typhus seems to be a genus comprehend-
ing several species. These, however, are not yet well
ascertained by observation; and in the mean time we
can perceive that many of the different cases observed,
do not imply any specific difference, but seem to be
merely varieties arising from a different degree of
power in the cause, from different circumstances of the
climate or season in which they happen, or from dif-
ferent circumstances in the constitution of the persons
affected.

71. Some of the effects arising from these circum-
stances require to be particularly explained.

One is, an unusual quantity of bile appearing in the
course of the disease. This abundance of bile may
possibly attend some continued fevers, strictly so called;
but, for the reasons above explained, it more com-
monly attends intermittents, and we believe it might
have been enumerated (29.) among the marks of dis-
tinguishing the latter kind of fevers from the former.
But though an unusual quantity of bile should appear
with continued fevers, it is considered in this case, as
in that of intermittents, to be a coincidence only, owing
to the state of the season, and producing no different
species or fundamental distinction, but merely a variety
of the disease. I think it proper to observe here, that
it is probable that the most part of the continued fevers
named Bilious, have been truly such as belong to the
section of Intermittents.

72. Another effect of the circumstances occasionally
varying the appearance of typhus, is a putrescent state
of the fluids. The ancients, and likewise the moderns,
who are in general much disposed to follow the former,
have distinguished fevers, as putrid, and non-putrid:

VOL. I. R

130 PRACTICE OF PHYSIC.

but the notions of the ancients, on this subject, were
not sufficiently correct to deserve much notice; and it
is only of late that the manner has been more accu-
rately observed, and better explained.

From the dissolved state of the blood, as it presents
itself when drawn out of the veins, or as it appears from
the red blood's being disposed to be effused and run off
by various outlets, and from several other symptoms to
be hereafter mentioned, I have now no doubt, how much
soever it has been disputed by some ingenious men,
that a putrescency of the fluids, to a certain degree, does
really take place in many cases of fever. This putres-
cency, however, often attends intermittent as well as
continued fevers, and of the continued kind, both the
synochus and typhus, and all of them in very different
degrees; so that, whatever attention it may deserve in
practice, there is no fixing such limits to it as to admit
of establishing a species under the title of putrid.

73. Beside differing by the circumstances already
mentioned, fevers differ also by their being accompanied
with symptoms which belong to diseases of the other
orders of pyrexias. This sometimes happens in such a
manner, as to render it difficult to determine which of
the two is the primary disease. Commonly, however, it
may be ascertained by the knowledge of the remote
cause, and the prevailing epidemic, or by observing the
series and succession of symptoms.

74. Most of our systems of physic have marked, as
a primary one, a species of fever under the title of hec-
tic ; but as it is described, I have never seen it as a
primary disease. I have constantly found it as a symp-
tom of some topical affection, most commonly of an
internal suppuration; and as such it shall be considered
in another place.

75. The distinction of the several cases of intermit-

PRACTICE OF PHYSIC. 131

tent fever I have not prosecuted here; both because we
cannot assign the causes of the differences which ap-
pear ; and because I apprehend that the differences
which in fact occur may be readily understood from
what is said above, (25. 26. and 21 '.) and more fully
from our Methodical Nosology, Ch. I. Sect. I.

CHAPTER I.

OF THE REMOTE CAUSES OF FEVER.

76. AS fever has been held to consist chiefly in an in-
creased action of the heart and arteries, physicians have
supposed its remote causes to be certain direct stimu-
lants fitted to produce this increased action. In many
cases, however, there is no evidence of such stimu-
lants being applied; and in those in which they are ap-
plied, they either produce only a temporary frequency
of the pulse, which cannot be considered as a disease;
or, if they do produce a permanent febrile state, it is by
the intervention of a topical inflammation, which pro-
duces a disease different from what is strictly called
fever. (8.)

77. That direct stimulants are the remote causes of
fever, seems farther improbable; because the supposi-
tion does not account for the phenomena attending the
accession of fevers, and because other remote causes
can with greater certainty be assigned.*

* Having already dwelt somewhat in detail on this subject, we shall here
simply remark, that we think the human mind can scarcely picture to itself
an error surpassing, in grossness, that which derives febrile diseases from
any thing but the action of stimulating causes. To attribute fever, which is
an increased state of action in living matter, to the influence of a sedative,

132 PRACTICE OF PHYSIC.

78. As fevers are so generally epidemic, it is proba-
ble, that some matter floating in the atmosphere, and
applied to the bodies of men, ought to be considered as
the remote cause of fevers: and these matters present
in the atmosphere, and thus acting upon men, may be
considered either as contagions, that is, effluvia aris-
ing directly or originally from the body of a man under
a particular disease, and exciting the same kind of dis-
ease in the body of the person to whom they are applied;
or miasmata, that is, effluvia arising from other sub-
stances than the bodies of men, producing a disease in
the person to whom they are applied.

79 Conta§ronly|iave been supposed to be of great
variety; and it is possible this may be the case; but that
they truly are so, does not appear clearly from any
thin^Sfeiv know at present. The genera and species of
contagious diseases, of the class of the Pyrexiae, at pre-
sent known, are in number not very great. They chiefly
belong to the order of Fevers, to that of Exanthemata,
or that of Profluvia. Whether there be any belonging
to the order of Phlegmasia), is doubtful; and though
there should, it will not much increase the number of
contagious pyrexiae. Of the contagious exanthemata
and profluvia, the number of species is nearly ascer-
tained, and each of them is so far of a determined na-
ture, that though they have now been observed and dis-
tinguished for many ages, and in many different parts of
the world, they have been always found to retain the
same general character, and to differ only in circum-
stances, that may be imputed to season, climate, and
other external causes, or to the peculiar constitutions
of the several persons affected. It seems, therefore,

which means something calculated to diminish action, is precisely as absurd
as it would be, to assign ice as the cause of burning, or flames of freezing.
It is to deal not merely in paradoxes, but in contraries.

PRACTICE OF PHYSIC. jgg

probable, that in each of these species, the contagion
is of one specific nature; and that the number of con-
tagious exanthemata or profluvia is hardly greater than
the number of species enumerated in the systems of
nosology.

80. If, while the contagious exanthemata and pro-
fluvia are thus limited, we should suppose the conta-
gious pyrexiae to be still of great and unlimited variety,
it must be with respect to the genera and species of
continued fevers. But if I be right in limiting, as I
have done, the genera of these fevers, (67. — 70.) it
will appear likely that the contagions which produce
them are not of great variety: and this \**ill be much
confirmed, if we can render it probable that there is
one principal, perhaps one common, source of such
contagion.

81. To this purpose it is now well known that the
effluvia constantly arising from the living human body,
if long retained in the same place, without being dif-
fused in the atmosphere, acquire a singular virulence;
and, in that state, being applied to the bodies of men, be-
come the cause of a fever which is highly contagious.

The existence of such a cause is full) proved by the
late observations on jail and hospital fevers: and that
the same virulent matter may be produced in many
other places, must be sufficiently obvious: and it is pro-
bable that the contagion arising in this manner, is not,
like many other contagions, permanent and constantly
existing; but that, in the circumstances mentioned, it
is occasionally generated. At the same time, the na-
ture of the fevers from thence, upon different occasions,
arising, renders it probable that the virulent state of
human effluvia is the common cause of them, as they
differ only in a state of their symptoms; which may
be imputed to the circumstances of season, climate,

134 ■ PRACTICE OF PHYSIC.

&c. concurring with the contagion, and modifying its
force.*

82. With respect to these contagions, though we have
spoken of them as of a matter floating in the atmos-
phere, it is proper to observe, that they are never found
to act but when they are near, to the sources from^
whence they arise; that is, either near to the bodies of
men, from which they immediately issue; or near to
some substances, which, as having been near to the
bodies of men, are imbued with their effluvia, and in
which substances these effluvia are sometimes retained
in an active state for a very long time.

The substances thus imbued with an active and in-
fectious matter, may be called, Fomites; and it appears
to me probable, that contagions, as they arise from fo-
mites, are more powerful than as they arise immediately
from the human body.f

* Having nothing further which we think it necessary to add, we shall
only here refer the reader to what we have already said on the subject of
febrile contagion.

f On the doctrine contained in this section is founded, in a great measure,
the practice of quarantine. It is, therefore, of the utmost importance to
commercial nations; and deserves, we think, a much more thorough and
philosophical examination than it has ever undergone.

Systems of quarantine were established in Europe, if not during the dark
ages, at least long before the blaze of physical knowledge, which now
exists, had opened on the world. ,

Since that period, the principles and opinions on which they were then
founded have undergone no actual revision, and but little alteration. The
interests of millions are suffered to be still under the control of laws and
usages established at an era of great ignorance. This is a proceeding which
is neither reasonable nor just ; nor is it honourable to the reputation of mo-
dern times.

In the countries of the old world, where the human mind is not a little
restricted by the trammels of precedent, it is scarcely probable that this
state of things will shortly undergo any material alteration. The son, there,
feels himself almost compelled by pious duty, to walk in the path which his
father has trodden. Hence the perpetuity of many an error.

But, in the United States, the case is different. If we are, in relation to
some points, without the lights of Europe to conduct us to what is right ;
we are, with respect to others, free from those prejudices and restraints

PRACTICE OF PHYSIC. 135

83. Miasmata are next to be considered. These may
arise from various sources, and be of different kinds;
but we know little of their variety, or of their several
effects. We know with certainty only one species of
miasma, which can be considered as the cause of fe-
ver; and, from the universality of this, it may be doubted
if there be any other.

84. This miasma, so universally the cause of fever,
is that which arises from marshes or moist ground,
acted upon by heat. So many observations have now
been made with respect to this, in so many different re-
gions of the earth, that there is neither any doubt of its
being in general a cause of fevers, nor of its being very
universally the cause of intermitting fevers in all their
different forms. The similarity of the climate, season,
and soil, in the different countries in which intermit-
tents arise, and the similarity of the diseases, though
arising in different regions, concur in proving, that there
is one common cause of these diseases, and that this k
the marsh miasma.

What is the particular nature of this miasma, we
know not, nor do we certainly know whether or not it
differs in kind; but it is probable that it does not; and

that might keep us in the wrong. Nor are these remarks inapplicable, as
we think, to the present question.

With us, systems of quarantine being of recent origin, the principles on
which they are erected have not as yet become inflexible with age — have
not degenerated into immutable canons. Would it not be well, therefore,
while they still may be changed, to inquire, with more strictness than has
been hitherto practised, into their truth and consequent fitness, to preserve
the health of those whose commercial interests they so seriously affect ?

Without asserting that the doctrine of Fomites is entirely unfounded, we
feel persuaded that it is replete with error.

Would it not be an act worthy of the government of the United States, to
institute, by authority, a thorough revision of it ? We are convinced, that
the science of legislation, a9 well as that ef medicine, would be benefited
by the project

136 PRACTICE OF PHYSK

that it varies only in the degree of its power, or per-
haps as to its quantity, in a given space.*

85. It has been now rendered probable, that the re-
mote causes of fevers (8.) are chiefly Contagions, or
Miasmata, and neither of them of great variety. We have
supposed that miasmata are the cause of intermittents,
and contagions the cause of continued fevers, strictly so
named; but we cannot with propriety employ these ge-
neral terms. For, as the cause of continued fevers may
arise from fomites, and may, in such cases, be called a
Miasma; and as other miasmata also may produce con-
tagious diseases ; it will be proper to distinguish the
causes of fevers, by using the terms Human or Marsh
Effluvia, rather than the general ones of Contagion or
Miasma.

86. To render our doctrine of fever consistent and
complete, it is necessary to add here, that those remote
causes of fever, hum^n and marsh effluvia, seem to be
of a debiliating or sedative quality. They arise from a
putrescent matter. Their production is favoured, and
their power increased, by circumstances which favour
putrefaction; and they often prove putrefactive ferments
with respect to the animal fluids. As putrid matter,
therefore, is always, with respect to animal bodies a
powerful sedative, so it can hardly be doubted, that hu-
man and marsh effluvia are of the same quality; and it
is confirmed by this, that the debility which is always
induced, seems to be in proportion to the other marks
that appear of the power of those causes.f

* We have long thought it probable, that the miasmata which produce
yellow fever differ from those that give rise to intermittents, somewhat as
the nitric does from the nitrous, and the sulphuric from the sulphureous
acids. We know not on what other ground to attempt an explanation of the
difference of their effects

f For a refutation of the doctrine of putridity, as applied to the fluids of

PRACTICE OF PHYSIC.

137

87. Though we have endeavoured to show that fevers
generally arise from marsh or human effluvia, we can-
not, with any certainty, exclude some other remote
causes, which are commonly supposed to have at least
a share in producing those diseases. And I proceed,
therefore, to inquire concerning these causes; the first
of which that merits attention, is the power of cold ap-
plied to the human body.

88. The operation of cold on a living body, is so dif-
ferent in different circumstances, as to be of difficult
explanation; it is here, therefore, attempted with some
diffidence.

The power of cold may be considered as absolute or
relative.

The absolute power is that by which it can diminish
the temperature of the body to which it is applied. And
thus, if the natural temperature of the human body is,
as we suppose it to be, that of 98 degrees of Fahren-
heit's thermometer;* every degree of temperature less
than that may be considered as cold with respect to the
human body; and, in proportion to its degree, will have
a tendency to diminish the temperature of the body.
But as the living human body has in itself a power of
generating heat, so it can sustain its own proper heat to
the degree above mentioned, though surrounded by air
or other bodies of a lower temperature than itself; and
it appears from observation, that, in this climate, air, or

living animals, we cannot do better than refer the reader to an exce'len In-
augural Dissertation, by Dr Seyben, published first in the year 179j and
republished in a volume of Select Medical Theses, by Thomas and Williahl
Bradford, for the year 1805. We shall, in the mean time, only obs< -u-, That
a quantity of matter actually putrid, introduced into the blood-vessels of
living animals, would prove as certainly and almost, as suddenly fatal as an
equal amount of boiling water.

* In every instance of our mentioning degrees of heat or cold, we shall
mention them by the degrees in Fahrenheit's scale : and tiic expression of
higher or lower shall always be according to that scale.— Cullen.
VOL. I. S

138 PRACTICE OF PHYSIC.

other bodies applied to the living man, do not diminish
the temperature of his body, unless the temperature of
the bodies applied be below 62 degrees. From hence it
appears, that the absolute power of cold in this climate,
does not act upon the living human body, unless
the cold applied be below the degree just now men-
tioned.

It appears also, that the human body's being sur-
rounded by air of a lower temperature than itself, is ne-
cessary to its being retained in its proper temperature
of 98 degrees: for in this climate, every temperature of
the air above 62 degrees, applied to the human body,
though still of a lower temperature than itself, is found
to increase the heat of it. And from all this it appears,
that the absolute pow r er of cold with respect to the hu-
man body, is very different trom what it is with respect
to inanimate bodies.*

89. The relative power of cold with respect to the
living human body, is that power by which it produces
a sensation of cold in it; and with respect to this, it is
agreeable to the general principle of sensation, that the
sensation produced, is not in proportion to the absolute
force of impression, but according as the new impres-
sion is stronger or weaker than that which had been
applied immediately before. Accordingly, with respect
to temperature, the sensation produced by any degree
of this depends upon the temperature to which the body
had been immediately before exposed; so that whatever

* Our author's view of cold, as a cause of fever, is exceedingly laboured,
obscure and unsatisfactory. That gent gives rise to fever on the same
principles with every other. On the part to which it is applied, it pro-
ducer an irritation. That irritation spreading by svmpathy from one organ
or-subdivision of the system to another, forms a chain of morbid action in
which the whole becomes ultimately involved A wound, the matter of
smai 1 pox, marsh miusmaia, an excessive close of arsenic or corrosive subli-
mate, and all other febrile causes act in the same way.

PRACTICE OF PHYSIC. 139

is higher than this feels warm, and whatever is lower
than it, feels cold; and it will therefore happen that the
opposite sensations of heat and cold may on different
occasions arise from the same temperature, as marked
by the thermometer.

With respect to this, however, it is to be observed, that
though every change of temperature gives a sensation
of cold or heat as it is lower or higher than the tempera-
ture applied immediately before, the sensation produced
is, in different cases, of different duration. If the tem-
perature at any time applied is under 62 degrees, every
increase of temperature applied will give a sensa-
tion of heat; but if the increase of temperature does
notarise to 62 degrees, the sensation produced will not
Continue long, but be soon changed to a sensation of
cold. In like manner, any temperature, applied to the
human body, lower than that of the body itself, gives a
sensation of cold; but if the temperature applied does
not go below 62 degrees, the sensation of cold will not
continue long, but be soon changed to a sensation of
heat.

It will appear hereafter, that the effects of the sensa-
tion of cold will be very different, according as it is
more permauentor transitory.

90. Having thus explained the operation of cold, as
absolute or relative, with respect to the human body, I
proceed to mention the general effects of cold upon it.

1. Cold, in certain circumstances, has manifestly a
sedative power. It can extinguish the vital principle en-
tirely, either in particular parts, or in the whole body;
and considering how much the vital principle of animals
depends upon heat, it cannot be doubted that the power
of cold is always more or less directly sedative.

This effect may be said to take place from every de-
cree of absolute cold ; and when the heat of the body

140 PRACTICE OF PHYSIC.

has upon any occasion been preternaturally increased,
every lower temperature may be useful in diminishing
the activity of the system; but it cannot diminish the
natural vigour of the vital principle, till the cold applied
is under 62 degrees; nor even then will it have this ef-
fect, unless the cold applied be of an intense degree, or
be applied for some length of time to a large portion of
the body.

2. It is equally manifest, that in certain circum-
stances, cold proves a stimulus to the living body, and
particularly to the sanguiferous system.

It is probable, that this effect takes place in every
case, in which the temperature applied produces a
sensation of cold; and this, therefore, as depending en-
tirely on the relative power of cold, will be in propor-
tion to the change of temperature that takes place.

It appears to me probable, that every change of tem-
perature, from a higher to a lower degree, will prove
more or less stimulant; excepting when the cold appli-
ed is so intense, as immediately to extinguish the vital
principle in the part.

3. Besides the sedative and stimulant powers of
cold, it is manifestly also a powerful astringent, causing
a contraction of the vessels on the surface of the body,
and thereby producing a paleness of the skin, and a
suppression of perspiration; and it seems to have simi-
lar effects when applied to internal parts. It is like-
wise probable, that this constriction, as it takes place
especially in consequence of the sensibility of the parts
to which the cold is applied, will in some measure be
communicated to other parts of the body; and that
thereby the application of cold proves a tonic power
with respect to the whole system.

These effects of tonic and astringent power seem to
take place both from the absolute and relative power

PRACTICE OF PHYSIC.

141

of cold; and therefore every application of it, which
gives a sensation of cold, is, in its first effect, both as-
tringent and stimulant, though the former may be often
prevented from being either considerable or perma-
nent, when the latter immediately lakes place.

91. It will be obvious, that these several effects of
eold cannot all take place at the same time, but may
in succession be variously combined. The stimulant
power taking place obviates the effects, at least the
permanency of the effects, that might otherwise have
arisen from the sedative power. That the same sti-
mulant power prevents these from the astringent, I have
said above; but the stimulant and tonic powers of cold
are commonly, perhaps always, conjoined.

92. These general effects of cold now pointed out
are sometimes salutary, frequently morbid; but it is the
latter only I am to consider here, and they seem to be
chiefly the following.

1. A general inflammatory disposition of the system,
which is commonly accompanied with Rheumatism, or
other Phlegmasias.

2. The same inflammatory disposition accompanied
with Catarrh.

3. A Gangrene of particular parts.

4. A Palsy of a single member.

5. A Fever, or Fever strictly so called (8.) which
it often produces by its own power alone, but more
eommonly it is only an exciting cause of fever by con-
curring with the operation of human or marsh effluvia.

93. Cold is often applied to the human body with-
out producing any of these morbid effects, and it is
difficult to determine in what circumstances it espe-
cially operates in producing them. It appears to me,
that the morbid effects of cold depend partly upon cer-

112 PRACTICE OF PHYSIC.

tain circumstances of the cold itself, and partly on cer-
tain circumstances of the person to whom it is applied.

94. The circumstances of the cold applied, which
seem to give it effect, are, 1. The intensity or degree
of the cold; 2. The length of time during which it is
applied; 3. The degree of moisture at the same time ac-
companying it; 4. Its being applied by a wind or cur-
rent of air; 5. Its being a vicissitude, or sudden and
considerable change of temperature, from heat to cold.

95. The circumstances of persons rendering them
more liable to be affected by cold, seem to be, 1. The
weakness of the system, and particularly the lessened
vigour of the circulation, occasioned by fasting, by
evacuations, by fatigue, by a last night's debauch, by
excess in venery, by long watching, by much study, by
rest immediately after great exercise, by sleep, and by
preceding disease. 2. The body, or its parts, being de-
prived of their accustomed coverings. 3. One part of
the body being exposed to cold, while the rest is kept
in its usual or a greater warmth.

96. The power of these circumstances (95) is de-
monstrated by the circumstances enabling persons to
resist cold. These are a certain vigour of constitution,
exercise of the body, the presence of active passions,
and the use of cordials.

Besides these, there are other circumstances which,
by a different operation, enable persons to resist cold
acting as a sensation; such as, passions engaging a close
attention to one object, the use of narcotics, and that
state of the body in which sensibility is greatly dimi-
nished, as in maniacs. To all which is to be added,
the power of habit with respect to those parts of the
body to which cold is more constantly applied, which
both diminishes sensibility and increases the power of
the activity generating heat.

PRACTICE OF PHYSIC. 143

97. Besides cold, there are other powers that seem
to be remote causes of fever; such as fear, intempe-
rance in drinking, excess in venery, and other circum-
stances, which evidently weaken the system. But
whether any of these sedative powers be alone the re-
mote cause of fever, or if they only operate either as
concurring with the operation of marsh or human efflu-
via, or as giving an opportunity to the operation of
cold, are questions not to be positively answered: they
may possibly of themselves produce fever, but most fre-
quently they operate as concurring in one or other of
the ways above mentioned.

98. Having now mentioned the chief of the remote
causes of fevers, it may be further observed, that
these will arise more or less readily, according as mi-
asmata and contagions are more or less prevailing
and powerful, or as these are more or less favoured
by the concurrence of cold and other sedative powers.

chapter v.

OF THE PROGNOSIS OF FEVERS.

99. AS fevers (by 60.) consist of both morbid and sa-
lutary motions and symptoms, the tendency of the dis-
ease to a happy or fatal issue, or the prognostic in fe-
vers, has been established by marking the prevalence of
the morbid or of the salutary symptoms; and it might
be properly so established, if we could certainly distin-
guish between the one and the other of these kind of
symptoms: but the operation of the reaction, or salu-
tary efforts of nature in curing fevers, is still involved
m so much obscurity, that I cannot explain the several

144 PRACTICE OF PHYSIC.

symptoms of it so clearly as to apply them to the esta-
blishing prognostics; and this, I think, may be done
better, by marking the morbid symptoms which show
the tendency to death in fevers.*

100. This plan of the prognostics in fevers must pro-
ceed upon our knowledge of the causes of death in ge-
neral, and in fevers more particularly.

The causes of death, in general, are either direct or
indirect.

The first are those which directly attack and destroy
the vital principle, as lodged in the nervous system; or
destroy the organization of the brain immediately ne-
cessary to the action of that principle.

The second, or the indirect causes of death, are those
which interrupt such functions as are necessary to the
circulation of the blood, and thereby necessary to the
due continuance and support of the vital principle-!

101. Of these general causes, those which operate
more particularly in fevers seem to be, first, The vio-
lence of reaction; which, either by repeated violent ex-

* Although it may be, and very probable is true, that all fevers consist of
a mixture of morbid and salutary motions, it is equally so that we have not
yet learnt to discriminate with accuracy between them. Nothing 1 would be
more dangerous, therefore, than an attempt to establish our prognosis on
that ground.

Indeed the doctrine or rather practice of prognosis is one in which all
practitioners, but especially young ones, ought to deal with the utmost cau-
tion. Although it is both natural and right for them to exercise their pene-
tration and sagacity in endeavouring to form some opinion as to the proba-
ble termination of every case of disease, prudence and a due regard to their
own reputation require of them not to be very liberal in the communication
of that opinion to others. One false prediction may do them an injury which
ten correct ones will not remedy. Let their prognosis, therefore, rest with
themselves, until the case be so clear that they cannot be deceived.

j- Under this head our author might have added another set of causes, viz.
those which deeply disorder the functions of the stomach. In the malignant bili-
ous or yellow fever, no symptom is of more fatal prognosis than an obsji-
nate vomiting. Indeed such is the importance of the stomach, as a seat and
centre of sympathy, that in every case wherein it is very seriously affected,
life must be considered as somewhat endangered.

PRACTICE OF PHYSIC. 145

citements, destroys the vital power itself; or, by its
violence, destroys the organization of the brain neces-
sary to the action .of that power; or, by the same vio-
lence, destroys the organization of the parts more im-
mediately necessary to the circulation of the blood.

Secondly, The cause of death in fevers may be a
poison, that is, a power capable of destroying the vital
principle; and this poison may be either the miasma
or contagion which was the remote cause of the fever,
or it may be a putrid matter generated in the course of
the fever. In both cases, the operation of such a power
appears either as acting chiefly on the nervous system,
inducing the symptoms of debility; or, as acting upon
the fluids of the body, inducing a putrescent state in
them.

102. From all this it appears, that the symptoms
showing the tendency to death in fevers, may be disco-
vered by their being either the symptoms

Of violent reaction;
Of great debility^;

Or, of a strong tendency to putrefaction in the fluids.
And upon this supposition, I proceed now to mark
those symptoms more particularly.*

103. The symptoms which denote the violence of re-
action, are, 1. The increased force, hardness, and fre-
quency of the pulse. 2. The increased beat of the
body. 3. The symptoms which are the marks of a
general inflammatory diathesis, and more especially of
a particular determination to the brain, lungs, and other
important viscera. 4. The symptoms which are the
marks of the cause of violent reaction; that is, of a

* It is much to be regretted that this doctrine of putrescency corrupts
the whole of our author's reasonings. Fortunately, however, it does not in*
juriously affect his practice — or, if at all, but very slightly. The remedies
which he administers to prevent or correct putrefaction, are such,' in gene-
ral, as, on sound principles, the case requires.
VOL. I. T

146 PRACTICE OF PHYSIC.

strong stimulus applied, or of a strong spasm formed,
the latter appearing in a considerable suppressionof
the excretions.*

101. The symptoms which denote a great degree of
debility, are,

In the animal functions: I. The weakness of the
voluntary motions; II. The irregularity of the volun-
tary motions, depending on their debility; III. The
weakness of sensation; IV. The weakness and irregu-
larity of the intellectual operations.

In the vital functions: I. The weakness of the
pulse; II. The coldness and shrinking of the extremi-
ties; III. The tendency to a detiquium animi in an erect
posture; IV. The weakness of respiration.

In the natural functions: I. The weakness of the
stomach, as appearing in anorexia, nausea, and vomit-
ing; II. Involuntary excretions, depending upon a palsy
of the sphincters; III. Difficult deglutition, depending
upon a palsy of the muscles of the fauces.

105. Lastly, The symptoms denoting the putrescent
state of the fluids, are,

I With respect to the stomach; the loathing of ani-
mal food, nausea, and vomiting, great thirst, and a de-
sire of acids.

II. With respect to the fluids; 1. The blood drawn
out of the veins not coagulating as usual; 2. Hemor-
rhagy from different parts, without marks of increased
impetus; 3 Effusions under the skin or cuticle, form-
ing petechias, macula?, and vibices; 4. Effusions of a
yellow serum under the cuticle.

* Our author's enumeration of the symptoms on which he foun<ls his prog-
nosis in fevers, although it might, we think, be somewhat extended, is one
of the most judicious portions of his work. As far as it goes, it is the re-
sult of correct observation, and a profound knowledge of t!ie human sys-
tem It merits, therefore, the particular attention of those who are in pur-
suit of practical medicine.

PRACTICE OF PHYSIC. 1 47

IN. With respect to the state of the excretions; fe-
tid breath, frequent, loose and fetid stools, high coloured
turbid urine, fetid sweats, and the fetor and livid colour
of blistered places.

IV. The cadaverous smell of the whole body.

106. These several symptoms have very often, each
of them singly, a share in determining the prognostic;
but more especially by their concurrence and combina-
tion with one another; particularly those of debility with
those of putrescency.

107. On the subject of the prognostic, it is proper to
observe, that many physicians have been of opinion
there is something in the nature of fevers which gene-
rally determines them to be of a certain duration; and
therefore that their terminations, whether salutary or
fatal, happen at certain periods of the disease rather
than at others. These periods are called the critical
days; carefully marked by Hippocrates and other an-
cient physicians, as well as by moderns of the greatest
eminence in practice; whilst at the same time many
other moderns of no inconsiderable authority, deny
their taking place in the fevers of these northern re-
gions which we inhabit*

* In addition to tlie professor's remarks on the Hippocratic doctrine of
critical days, which, in the main, we believe, has a foundation in nature,
we shall only observe, that we think there is scarcely a position in medi-
cine more clear!} established, than that regular intermitients are marked by
hebdomadal periods If attended to at the commencement, they may be
brought to& perfect termmation, almost with certainty, at the end o! a week —
seldom, perhaps, in a much shorter period— and, if any improper exposure
be sustained by the patients, they will be likely to recur about the expira-
tion of the next or the second week. As an excellent practical rule, there-
fore, let preventive remedies be employed until the end of a fortnight afcer
the termination of these diseases.

The best preventives are, suitable clothing", a careful avoidance of excit-
ing causes, a generous diet, regulated, however, by the state of the system,
and the use of the bark, or strong infusions of chamomile, centaury, quassia,
or other bitters.

148 PRACTICE OF PHYSIC.

108. I am of opinion that the doctrine of the ancients,
and particularly that of Hippocrates, on this subject,
was well founded; and that it is applicable to the fevers
of our climate.

109. I am of this opinion, first, Because I observe
that the animal economy, both from its own constitu-
tion, and from habits which are easily produced in it, is
readily subjected to periodical movements. Secondly,
Because, in the diseases of the human body, I observe
periodical movements to take place with great constancy
and exactness; as in the case of intermittent fevers, and
many other diseases,

110. These considerations render it probable, that
exact periodical movements may take place in continued
fevers; and I thiuk there is evidence of such movements
actually taking place. <

111. The critical days, or those on which we suppose
the termination of continued fevers especially to happen,
are, the third, fifth, seventh, ninth, eleventh, fow teenth y
seventeenth, and twentieth. We mark none beyond this
last; because, though fevers ate sometimes protracted
beyond this period, it is, however, more rarely; so that
there are not a sufficient number of observations to
ascertain the course of them; and further, because it is
probable that, in fevers long protracted, the movements
become less exact and regular, and therefore less easily
observed.

112. That the days now mentioned are the critical
days, seems to be proved by the particular facts which are
found in the writings of Hippocrates. From these facts,
as collected from the several writings of that author by
M. de Haen, it appears, that of one hundred and sixty-

A due attention to these precautions could not fail to render relapses much
less frequent than they usually are.

PRACTICE OF PHYSIC. 149

three instances of the termination of fevers, which hap-
pened on one or other of the first twenty days of the
disease, there are one hundred and seven, or more than
two-thirds of the whole number, which happened on
one or other of the eight days above mentioned; that
none happened on the second or thirteenth day, and
upon the eighth, tenth, twelfth, fifteenth, sixteenth,
eighteenth, and nineteenth, there are but eighteen in-
stances of termination, or one ninth of the whole.

113. As the terminations which happen on the seven
days last mentioned, are, upon the whole, few; and, up-
on any one of them, fewer than those which happen on
any one of our supposed critical days; so there are there-
fore nine days which may be called non-critical;
while, on the other hand, the many terminations which
happened on the seventh, fourteenth, and twentieth
days, afford a proof both of critical days in general, and
that these are the chief of them. Hereafter I shall men-
tion an analogy that renders the power of the other
critical days sufficiently probable.

114. It appears further, that as, of the terminations
which were final and salutary, not a tenth part hap-
pened on the non-critical days; and of the terminations
which were final and fatal, though the greater number
happened on the critical days, yet above a third of them
happened on the non-critical; so it would appear that
the tendency of the animal economy is to observe the
critical days, and that it is by the operation of some
violent and irregular cause that the course of things is
sometimes turned to the non-critical.

1 15. What has been said gives sufficient ground for
presuming, that it is the general tendency of the animal
economy to determine the periodical movements in fe-
vers to be chiefly on the critical days. At the same time,
we must acknowledge it to be a general tendency only;

150 PRACTICE OF PHYSIC.

and that in particular cases, many circumstances may
occur to disturb the regular course of it. Thus, though
the chief and more remarkable exacerbations in con-
tinued fevers happen on the critical days, there are truly
exacerbations happening every day; and these, from
certain causes, may become considerable and critical.
Further, though intermittent fevers are certainly very
strongly determined to observe a tertian or quartan
period, we know there are certain circumstances which
prevent them from observing these periods exactly, and
which render them either anticipating or postponing so
much, that the days of paroxysms come to be quite
changed; and it is allowable to suppose that the like
may happen with respect to the exacerbations of con-
tinued fevers, so as thereby to disturb the regular ap-
pearance of critical days.

A particular instance of this occurs with respect to
the sixth day of fevers. In the writings of Hippocrates,
there are many instances of terminations happening on
the sixth day; but it is not therefore reckoned among
the critical days; for of the terminations happening on
that day, there is not one which proves finally of a
salutary kind; the greater number are fatal; and all the
rest are imperfect, and followed with a relapse. All
this shows, that some violent cause had, in these cases,
produced a deviation from the ordinary course of na-
ture; that the terminations on the sixth day are nothing
more than anticipations of the seventh, and therefore a
proof of the power of this last.

116. The doctrine of critical days has been much
embarrassed by some dissonant accounts of it, which
appear in the writings imputed to Hippocrates. But this
may be justly accounted for from these writings being
truly the works of different persons, and from the most
genuine of them having suffered many corruptions; so

PRACTICE OF PHYSIC. 15]

that, in short, every thing which is inconsistent with the
facts above laid down, may be ascribed to one or other
of these causes.

117. This, further, has especially disturbed the doc-
trine of critical days, that Hippocrates himself attempt-
ed, perhaps too hastily, to establish general rules, and to
bring the doctrine to a general theory, drawn from Py-
thagorean opinions concerning the power of numbers.
It is this which seems to have produced the idea of odd
days, and of a quaternary and septenary period, doc-
trines which appear so often in the writings of Hippo-
crates. These, however, are inconsistent with the facts
above laid down; and, indeed, as Asclepiades and Cel-
sus have observed, are inconsistent with one another.

118. Upon the whole, therefore, it is apprehended,
that the critical days above assigned are truly the criti-
cal days of Hippocrates, and may be consistently ex-
plained in the following manner.

119. From the universality of tertian or quartan pe-
riods in intermittent fevers, we cannot doubt of there
being, in the animal economy, a tendency to observe
such periods; and the critical days above mentioned
are consistent with this tendency of the economy, as all
of them mark either tertian or quartan periods. These
periods, however, are not promiscuously mixed, but
occupy constantly their several portions in the progress
of the disease; so that, from the beginning to the
eleventh day a tertian period takes place, and from the
eleventh to the twentieth, andperhaps longer, a quartan
period is as steadily observed.

120. What determines the periods to be changed
about the eleventh day, we have not clearly perceived;
but the fact is certain: for there is no instance of any
termination on the thirteenth, that is, the tertian period
next following the eleventh; whereas upon the lour-

152 PRACTICE OF PHYSIC.

teenth, seventeenth, and twentieth, which mark quartan
periods, there are forty-three instances of terminations,
and six only on all the intermediate davs between these.
This prevalence of a quartan period leaves no room
for doubting that the twentieth, and not the twenty-first,
is the critical day marked by Hippocrates, though the
last is mentioned as such in the common edition of the
Aphorisms, taken from an erroneous manuscript, which
Celsus also seems to have copied.

121. A consistency with the general tendency of the
system renders the series of critical days we have men-
tioned, probably the true one; and the only remaining
difficulty in finding what we have delivered to be the
same with the genuine doctrine of Hippocrates, is the
frequent mention of the fourth as a critical day.

It is true there are more instances of terminations
happening on this day, than on some of those days we
have asserted to be truly critical: but its inconsistency
with the more general tendency, and some other consi-
derations, lead us to deny its being naturally a critical
day; and to think that the instances of terminations,
which have really occured on the fourth day, are to be
reckoned among the other irregularities that happen in
this matter.

122. I have thus endeavoured to support the doctrine
of critical days, chiefly upon the particular facts to be
found in the writings of Hippocrates: And although I
might also produce many other testimonies of both an-
cient and modern times, yet it must be owned, that some
of these testimonies may be suspected to have arisen
rather from a veneration of Hippocrates, than from ac-
curate observation.

123. With respect to the opinions of many moderns
who deny the prevalence of critical days, they are to be
little regarded, for the observation of the course of con-

PRACTICE OF PHYSIC. 15$

tinned r evers is known to be difficult and fallacious; and
therefore the regularity of that course may have often
escaped inattentive and prejudiced observers.

124 Our own observations amount to this, That fe-
vers with moderate symptoms, generally the cases of
the synocha, frequently terminate in nine days, or sooner,
and very constantly upon one or other of the critical days
which fall within that period: but it is very rare, in this
climate, that cases of either the typhus or synochus ter-
minate before the eleventh day: and when they do ter-
minate on this day, it is for the most part fatally. When
they are protracted beyond this time, I have very con-
stantly found, that their terminations were upon the
fourteenth, seventeenth, or twentieth day.

In such cases, the salutary terminations are seldom
attended with any considerable evacuation. A sweating
frequently appears, but is seldom considerable; and I
have hardly ever observed critical and deci ive termina-
tions attended with vomiting, evacuations by stool, or
remarkable changes in the urine. The solution of the
disease is chiefly to be discerned from some return of
sleep and appetite, the ceasing of delirium, and an abate-
ment of the frequency of the pulse. By these symptoms
we can often mark a crisis of the disease: but it seldom
happens suddenly and entirely; and it is most commonly
from some favourable symptoms occurring upon one
critical day, that we can announce a more entire solu-
tion upon the next following.

Upon the whole, I am persuaded, that if observations
shall be made with attention, and without prejudice, I
shall be allowed to conclude with the words of the
learned and sagacious Ganbius, " Fallor, ni sua consti-
terit Hippocrati auctoritas, Galeno fides, nature
virtus et ordo."

vol. i. u

154 PRACTICE OF PHYSIC.

CHAPTER VI.*
OF THE METHOD OF CURE IN FEVERS.
Sect. I. — Of the Cure of Continued Fevers.

125. AS it is allowed, that in every fever which has its
full course, there is an effort of nature of a salutary
tendency, it might be supposed that the cure of fevers
should be left to the operations of nature, or that our
art should be only directed to support and regulate these
operations, and that we should form the indications ac-
cordingly. This plan, however, I cannot adopt, because
the operations of nature are very precarious, and not so
well understood as to enable us to regulate them pro-
perly. It appears to me, that trusting to these opera-
tions has often given occasion to a negligent and inert
practice; and there is reason to believe, that an attention
to the operations of nature may be often superseded
by art.f

* This chapter being intended to develop the general principles of prac-
tice in febrile diseases, is one of the most important in the whole work From
the pupil therefore, who is true to himself, it will receive a corresponding
degree of attention. If not actually committed to memory, it should, at
least, be studied with such labour and fidelity of research, that every prin-
ciple of it may be accurately retained.

| Although it is doubtless true, that the practitioner of medicine should
be cautious not to trust too far to the operations of Nature, he may notwith-
standing derive, at times, from that source, some of his most important indi-
cations of cure. Instead of neglecting Nature, therefore, or in the empbati-
cal language of a late medical leacher, " turning her out of doors," let him
patiently and studiously watch her movements.

In the commencement of an epidemic disease, she is sometimes his best, if
not his only instructor. She makes an obvious effort to relieve the sick
through some of the emunctork s He will be safe, for the most part; in fol-
lowing her example. If the effort be made through the bowels, let him

PRACTICE OF PHYSIC. 155

126. The plan which to me appears to be most suita-
ble is that which forms the indications of cure upon the
view of obviating the tendency to death ; while at the
same time the means of executing these indications are
directed by a proper attention to the proximate cause
of fevers.

Upon this plan, in consequence of what has been laid
down above on the subject of the prognostic, we form
three general indications in the cure of continued fe-
vers; and the one or other of these is to be employed
according as the circumstances* of the fever (102.)
shall direct.

The first therefore is, To moderate the violence of re-
action.

The second is, To remove the causes or obviate the
effects of debility. And,

The third is, To obviate or correct the tendency of the
fluids to putrefaction.

127. The first indication may be answered, that is,
the violence of reaction may be moderated,

1. By all those means which diminish the action of
the heart and arteries.

2. By those means which take off the spasm of the
extreme vessels, which we suppose to be the chief cause
of violent reaction.

purge; if through the skin, let him encourage a perspiration ; and if, as is
sometimes the case, hemorrhagies appear in an early stage of the disease,
venesection may be generally employed with advantage.

Some of the physicians of Philadelphia must well recollect to have seen
these positions abundantly confirmed in the epidemic fever which they so
often witnessed between the years 1793 and 1805.

A strong desire for wine and acids, in cases where those articles are
essential as remedies, constitutes another instance in which Nature assists the
practitioner in forming correct indications of cure.

That physician who, in the treatment of diseases, renders his labours at
all tirae» faithfully ancillary to those of nature, acquits himself of a very im-
portant branch of his duty.

156 PRACTICE OF PHYSIC.

128. The action of the heart and arteries may be
diminished,

1. By avoiding or moderating those irritations, which,
in one degree or other, are almost constantly applied to
the body.

2. By the use of certain sedative powers.

3. By diminishing the tension and tone of the arterial
system.

129. The irritations (128. 1.) almost constantly ap-
plied, are the impressions made upon our senses; the
exercise of the body and mind; and the taking in of
aliments. The avoiding these as much as possible, or
the moderating their force, constitute what is rightly
called the antiphlogistic regimen, proper to be em-
ployed in almost every continued fever.

130. The conduct of this regimen is to be directed
by the following rules and considerations.*

* In conducting the sick through a strict course of antiphlogistic regimen,
the (wo greatest difficulties with which physicians have to contend, is a de-
sire in their patients to take improper exercise, and in their nurses and
attendants that they should take improper food. The latter, in particular,
is oftentimes a source of great mischief. In febrile diseases of high action,
nothing should be received into the stomach that is not in a liquid state ; as
sago, panado, tapioca, water gruel, or some such mild vegetable nutriment.
Solid food is totally inadmissible. The stomach being unable to master and
digest it, it acts on that organ like an extraneous and insoluble substance,
producing in it great irritation, which, through the medium of sympathy, is,
in a short time, communicated to the whole system. In cases where conva-
lescence had already commenced, a few mouthfuls of solid food, particularly
animal food, has frequently produced relapses dangerous aHd even fatal.

The only drinks that are compatible with the antiphlogistic regimen, are
<Hich as are thin, mild, and diluting. Simple water, toast water, lemonade,
lintseed tea, barley water, apple water, a solution of gum arabic in water,
currant jelly dissolved in water, with othersimilar articles, are most suitable.

Where the object is to remove severe thirst, which, in cases of fever, ope-
rates as a powerful and injurious irritant, acidulated drinks are most effica-
cious. In preparing them the native vegetable acids should be preferred.
Vinegar and the mineral acids act too powerfully on the stomach, and are,
therefore, improper. In febrile cases of violent reaction, we think them
always injurious. In typhus they are more admissible. The juice of limes and
lemons, oranges and apples, currants and grapes, is grateful and beneficial.

PRACTICE OF PHYSIC. 157

1. Impressions on the external senses, as being stimu-
lant to the system, and a chief support of its activity,
should be avoided as much as possible; those especially
of more constant application, those of a stronger kind,
and those which give pain and uneasiness.

No impression is to be more carefully guarded against
than that of external heat; while at the same time every
other means of increasing the heat of the body is to be
shunned. Both these precautions are to be observed as
soon as the hot stage is fully formed, and to be attended
to during its continuance; excepting in certain cases,
where a determination to sweating is necessary, or

It is, in many instances, of great importance to remove the irritation of
retained feces, by injections, as our author proposes, rather than by purga-
tives The latter disorder the stomach, and, through that medium, the whole
system ; while the former merely carry off the offending matter, without
producing any distressing or injurious commotion. Besides, injections by
being well prepared and skillfully administered, may be made to operate
with great force. It is not true, as is usually observed, that they act only on
the lower intestines. Under proper management, and when frequently
repeated, they evacuate effectually the whole canal.

Mild injections may consist of tepid water alone, milk and water, or mo-
lasses and water, either with or without the addition of a little sweet oil. To
render them more active, add a table spoonful or two of muriate of soda, or
sulphate of soda, and castor oil instead of sweet oil. The amount of the oil
may be about two ounces ; and of the whole injection, if for an adult, at
least a pint, or even more, in case a powerful effect be required.

From twelve to fifteen or twenty grains of tartarized antimony, dissolved in
a suitable medium and thrown up the rectum, operate very powerfully in
evacuating the bowels. This preparation extends its influence to the sto-
mach itself. In cases of colic, it is sometimes very effectual in dissolving the
spasm which prevents the peristaltic motion of the intestines.

Injections of co Id -water have been found to be productive of a similar
effect.

But, perhaps the most powerful injection that can be prepared is a decoc-
tion of tobacco. Into a quart of water put a drachm of the leaves of that
plant, and boil it down to a pint. This forms an injection which scarcely
any obstinacy of stricture or constipation can resist.

In general, moderately stimulating injections are most suitable in cases of
fever. The more drastic ones are rarely called for except in colic, stran-
gulated hernia, and other instances of obstinate costivene-ss or dangerous
spasm.

158 PRACTICE OF PHYSIC.

where the stimulant effects of heat may be compensated
by circumstances which determine it to produce a re-
laxation and revulsion.

2. All motion of the body is to be avoided, especially
that which requires the exercise of its own muscles;
and that posture of the body is to be chosen which em-
ploys the fewest muscles, and which keeps none of
them long in a state of contraction. Speaking, as it
accelerates respiration, is particularly to be refrained
from.

It is to be observed, that every motion of the body
is the more stimulant, in proportion as the body is
weaker.

3. The exercise of the mind also is a stimulus to the
body; so that all impressions, which lead to thought,
and those especially which may excite emotion or pas-
sion, are to be carefully shunned.

With respect to avoiding impressions of all kinds, an
exception is to be made in the case of a delirium com-
ing on, when the presenting of accustomed objects may
have the effect of interrupting and diverting the irregu-
lar train of ideas then arising in the mind.

4. The presence of recent aliment in the stomach
proves always a stimulus to the system, and ought
therefore to be as moderate as possible. A total absti-
nence for some time may be of service; but as this can-
not be long continued with safety, we must avoid the
stimulus of aliment, by choosing that kind which gives
the least. We suppose that alimentary matters are
more stimulant, according as they are more alkalescent;
and this leads to avoid all animal, and to use vegetable
food only.

As our drinks also may prove stimulant, so all aro-
matic and spirituous liquors are to be avoided; and in
answering the present indication, all fermented liquors,

PRACTICE OF PHYSIC.

159

excepting those of the lowest quality, are to be ab-
stained from.

131. Besides these stimulant powers more constantly
applied, there are others which, although occasionally
only, yet, as commonly accompanying fevers, must be
attended to and removed.

One is, the sense of thirst, which, as a powerful sti-
mulus, ought always, in one way or other, to be removed.

Another stimulus frequently arises from crudities, or
corrupted humours in the stomach; and it is to be re-
moved by vomiting, by dilution, or by the use of acids.

A third stimulus often arises from the preternatural
retention of fasces in the intestines, and ought to be
removed by frequent laxative glysters.

A fourth stimulus to be constantly suspected in fe-
vers, is a general acrimony of the fluids, as produced
by the increase of motion and heat, joined with an in-
terruption of the excretions. This acrimony is to be
obviated or removed by the taking in of large quanti-
ties of mild and antiseptic liquors.

132. The avoiding of irritation in all these particu-
lars, (130. and 131.) constitutes the antiphlogistic regi-
men absolutely necessary for moderating the violence of
reaction; and, if I mistake not, is proper in almost
every circumstance of continued fevers; because the
propriety and safety of employing stimulants is often
uncertain; and because several of those above men-
tioned, beside their stimulant powers, have other quali-
ties by which they may be hurtful.

It appears to me, that the supposed utility of stimu-
lants, in certain cases of fever, has often arisen from a
mistake in having ascribed to their stimulant, what
reallv depended upon their antispasmodic power.

133. A second head of the means (128. 2.) for mo-
derating the violence of reaction, comprehends certain

160 PRACTICE OF PHYSIC.

sedative powers, which may be employed to diminish
the activity of the whole body, and particularly that of
the sanguiferous system.

Theirs* of these to be mentioned is the application
of cold.

Heat is the chief support of the activity of the animal
system; which is therefore provided in itself with a
power of generating heat. But, at the same time, we ob-
serve, that this would go to excess, were it not con-
stantly moderated by a cooler temperature in the sur-
rounding atmosphere. When, therefore, that power of
the system generating heat is increased, as is commonly
the case in fevers, it is necessary not only to avoid all
means of increasing it further, but it seems proper also
to apply air of a cooler temperature; or at least to apply
it more entirely and freely, than in a state of health.

Some late experiments in the small pox and in con-
tinued fevers, show that the free admission of cool air
to the body, is a powerful remedy in moderating the
violence of reaction; but what is the mode of its opera-
tion, to what circumstances of fever it is peculiarly
adapted, or what limitations it requires, I shall not ven-
ture to determine, till more particularly instructed by
further experience.*

* Cold, as an antiphlogistic remedy, should never be applied in so high a
degree as to produce a disagreeable sensation. If it be, it will certainly irri-
tate and prove injurious. When so employed as gradually to evacuate calo-
ric from the system, and remove the distressing sensation of heat, it does
good.

In the treatment of f brile diseases, the air of bed-chambers should be
always kept at a moderate temperature — so as to be perfectly grateful to
the feelings of the sick- not so as l<> produce chilliness. When the febrile
heat is high and burning, and the skin drj, the continued application of cold
water to the hands, wrists, and tenples, and sometimes also to the feet and
ancles, proves exceedingly pleasant, and is, at the same time, highly effica-
cious in moderating the excess of arterial action. The water may br applied
either by means of wet cloths, frequently renewed, or by repeated arT«.

PRACTICE OF PHYSIC. 161

134. A second sedative power, which may be em-
ployed in fevers, is that of certain medicines, known, in
the writings on the Materia Medica, under the title of

REFRIGERANTS.

The chief of these are acids of all kinds, when suffi-
ciently diluted; and they are, in several respects, reme-
dies adapted to continued fevers. Those especially in
use are, the Vitriolic and Vegetable; and, on many ac-
counts, we prefer the latter.

135. Another set of refrigerants are, the Neutral
Salts, formed of the vitriolic, nitrous, or vegetable acids;
with alkalines, either fixed or volatile. All these neutrals,
while they are dissolving in water, generate cold; but as
that cold ceases soon after the solution is finished, and
as the salts are generally exhibited in a dissolved state,
their refrigerant power in the animal body does not at
all depend upon their power of generating cold with
water. The neutral chiefly employed as a refrigerant,
is Nitre; but all the others, compounded as above men-
tioned, partake more or less of the same quality.*

sions. In this case particularly great caution is requisite, lest some degree
of chillness result from the operation.

Having but little experience in the practice of either general affusion, or
sponging the body and extremities with cold water, in febrile diseases, we
do not feel authorised to offer, on that subject, any remarks. From the re-
ports, however, of practical writers of high standing, we are not permitted
to doubt of their efficacy.

* The addition of tartarized antimony to nitre, when not forbidden by the
condition of the stomach, or some other particular cause, increases very
greatly its febrifuge powers.

Ten or twelve grains of the nitre combined with the sixth or eighth of a
grain of the antimony — in some cases with the fourth of a grain — and admi-
nistered every two hours, or oftener, if the stomach can bear it, is an active,
remedy in the reduction of fever.

Some practitioners prefer to the tartarized antimony, the addition of a
grain or two of ipecacuanha to each dose of the nitre.

In these cases, the salutary effect is rarely, if ever, produced, unless some
degree of nausea be experienced from the remedy. The stomach then
sympathizes with the vascula? system, and moderates its action.
VOL. I. X

162 -PRACTICE OF PHYSIC.

136. Besides these neutrals, some metallic salts also
have been employed as refrigerants in fevers; and par-
ticularly the Sugar of Lead. But the refrigerant powers
of this are not well ascertained; and its deleterious qua-
lities are too well known to admit of its being freely
used.*

137. Under the third general head (128. 3.) of the
means to be employed for moderating the violence of
reaction, are comprehended the several means of dimi-
nishing the tension, tone, and activity of the sanguife-
rous system. As the activity of this system depends, in
a great measure, upon the tone, and this again upon
the tension of the vessels, given to them by the quan-
tity f fluids they contain, it is evident that the diminu-
tion of the quantity of these must diminish the activity
of the sanguiferous system.

138. The quantity of fluids contained in the sangui-
ferous system, may be diminished most conveniently by
the evacuations of blood-letting and purging.

139. Nothing is more evident, than that blood-letting
is one of the most powerful means of diminishing the
activity of the whole body, especially of the sanguife-
rous system; and it must therefore be the most effectual
means of moderating the violence of reaction in fevers.
Taking this as a fact, I omit inquiring into its mode of
operation, and shall only consider in what circum-
stances of fevers it may be most properly employed.

140. When the violence of reaction, and its constant
attendant, a phlogistic diathesis, are sufficiently mani-
fest; when these constitute the principal part of the
disease, and may be expected to continue throughout

* Sugar of lend, exhibited in combination with opium, proves useful in
cases of febme hemorrhagy ; but we have never known it to be administer-
ed with advantage as a mere febrifuge. From two to five grains of the su-
gar, in combination with half a grain of opium, may be given with safety at
3 dose, and repeated as often as circumstances require.

PRACTICE OF PHYSIC. 163

the whole of it, as in the case of synocha; then blood-
letting is the principal remedy, and may be employed ad
far as the symptoms of the disease may seem to require,
and the constitution of the patient will bear. It is, how-
ever, to be attended to, that a greater evacuation than is
necessary, may occasion a slower recovery, may render
the person more liable to a relapse, or may bring on
other diseases.

141. In the case of synocha, therefore, there is little
doubt about the propriety of blood-letting: but there
are other species of fever, as the synochus, in which a
violent reaction and phlogistic diathesis appear, and
prevail during some part of the course of the disease;
while, at the same time, these circumstances do not
constitute the principal part of the disease, nor are to
be expected to continue during the whole course of it,
and it is well known, that in many cases the state of
violent reaction is to be succeeded, sooner or later, by
a state of debility, from the excess of which the dan-
ger of the disease is chiefly to arise. It is, therefore,
necessary, that, in many cases, blood-letting should be
avoided, and even although, during the inflammatory
state of the disease, it may be proper, it will be neces-
sary to take care that the evacuation be not so large as
to increase the state of debility which is t© follow.

142. From all this it must appear, that the employ-
ing blood-letting, in certain fevers, requires much dis-
cernment and skill, and is to be governed by the con-
sideration of the following circumstances;

1. The nature of the prevailing epidemic.

2. The nature of the remote cause.

3. The season and climate in which the disease oc-
curs.

4. The degree of phlogistic diathesis present.
o. The period of the disease,

164 PRACTICE OF PHYSIC.

6. The age, vigour, and plethoric state of the patient.

7. The patient's former diseases and habits of blood-
letting.

8. The appearance of the blood drawn out.

9. The effects of the blood-letting that may have
been already practised.*

* There are in medicine but few points that are attended with greater
difficulty, than to give abstract rules for the practice of blood-letting. In
relation to this remedy, every case of disease resembles precisely a case in
equity — it must be governed by its own circumstances; and, it is needless
to add, that there are very few,cases exactly alike.

Of the nine precautions which our author has here given, on the subject
of blood-letting, there are four, which, for correctness and weight, cannot
rank with his precepts in general. They are
1st. "The nature of the remote cause."

We are at a loss to perceive what material influence this can have in re-
lation to blood-letting. Our practice is to be directed, not by the remote,
but by the proximate causes of disease. Th's the professor has himself, in
another place, expressly acknowledged. "The cure of diseases," says he,
"is chiefly, and almost unavoidably, founded in the knowledge of their
proximate causes." Whence is it, then, that he here attaches so much im-
portance to the remote cause ? It is certainly to the proximate cause or
•nture of the disease, as far as it can be discovered, that all our remedies
ought to be suited.
2d. "The season and climate in which the disease occurs."
These are considerations, which, with the experienced physician, have
but little weight when he is making up his mind on the subject of blood-let-
ting. If other circumstances call for it, he will bleed in August as readily
as in January, and beneath the equator with as little hesitation as within the
polar circles. He will be governed in his practice by neither circumstance,
but exclusively by the state of his patient's system.
3d. " The period of the disease."

This consideration has some weight ; but by no means so much as is
usually claimed for it. As a general rule, the early stages of fever are those
in which blood-letting is most safe and efficacious : but its utility, as a remedy,
is not confined exclusively to these. It is oftentimes employed with great
advantage in an advanced age.

4th. "The age, vigour, and plethoric state of the patient."
Whatever weight these considerations may have in determining the quan-
tity of blood that ought to be drawn, they can have exceedingly little in set-
tling the question as to the propriety of the operation.

The diseases of childhood and old age call for blood-letting no less impe-
riously than those of manhood; and it is well known, that the lean and deli-
cate are oftentimes subject to the most inflammatory complaints.
Regardless, therefore, of age and habit, we say again, let the physician at-

PRACTICE OF PHYSIC. 165

143. When, after the consideration of these circum-
stances, blood-letting is determined to be necessary, it
should be observed, that it is more effectual, according
as the blood is more suddenly drawn off, and as the
body is at the same time more free from all irritation,
and consequently when in a posture in which the few-
est muscles are in action.

144. Another evacuation whereby the quantity k of
fluids contained in the body can be considerably dimi-
nished, is that of purging.

145. If we consider the quantity of fluids constantly
present in the cavity of the intestines, and the quantity
which can be drawn from the innumerable excretories
that open into this cavity, it will be obvious that a very
great evacuation can be made by purging; and, if this
be done by a stimulus applied to the intestines, without
being at the same time communicated to the rest of
the body, it may, by emptying both the cavity of the
intestines, and the arteries which furnish the excretions
poured into it, induce a considerable relaxation in the
whole system; and therefore, purging seems to be a re-
medy suited to moderate the violence of reaction in fe-
vers.

146 But it is to be observed, that as the fluid drawn
from the excretories opening into the intestines, is not
all drawn immediately from the arteries, as a part of it
is drawn from the mucous follicles only; and what is
even more immediately drawn from the arteries, is
drawn off slowly, so the evacuation will not, in propor-
tion to its quantity, occasion such a sudden depletion of
the red vessels, as blood-letting does; and therefore can-
not operate so powerfully in taking off the phlogistic
diathesis of the system*

tend with strictness to the state of his patient's system, and he will rarely
err as to the practice of blood-letting'.

* In bilious fevers, and all others where there is an excess of action in the

166 PRACTICE OF PHYSIC.

147. At the same time, as this evacuation may induce
a considerable degree of debility; so, in those cases, in
which a dangerous state of debility is likely to occur,
purging is to be employed with a great deal of caution;
and more especially as the due measure of the evacua-
tion is more difficult to be applied than in the case of
blood-letting.*

148. As we shall presently have occasion to observe,
that it is of great importance, in the cure of fevers, to
restore the determination of the blood to the vessels on
the surface of the body; so purging, as in some mea-
sure taking off that determination, seems to be an eva-
cuation not well adapted to the cure of fevers.

149. If, notwithstanding these doubts, (146. 147. and
148.) it shall be asserted, that purging, even from the
exhibition of purgatives, has often been useful in fevers;
I would beg leave to maintain, that this has not hap-
pened from a large evacuation; and therefore, not by
moderating the violence of reaction, excepting in the
case of a more purely inflammatory fever, or of exan-
themata of an inflammatory nature. In other cases of

viscera of the abdomen, copious purging is an indispensable remedy. Be-
sides removing the irritation of the faeces, it acts like topical depletion, by
cups or leeches, on an inflamed part

* The caution inculcated in this section is very important. In cases of
great debility, plentiful purging is a dangerous process, unless where the
debility arises, as it sometimes does, from a morbid irritation in the stomach
or bowels. In such a case the removal of the irritation augments the strength.

Towards the close of fevers, when the strength of patients is greatly ex-
hausted, severe purging has been known to be productive of death from
syncope. This, however, has been more particularly the case, when, in-
stead of remaining in a recumbent posture, and making use of abed-pan,
the sick have risen up, and made improper exertions in going from the bed
to the close-stool In the Influenza of 1815. a patient under our own care,
who had passed in safety through the disease, lost his life in this way. He
took a saline purgative, but was directed not to leave his bed He neglected
the advice, made an attempt to go to the close-stool, fainted, and never re
covered. In cases of great debility, such a practice should be rigidly pro-
hibited.

PRACTICE OF PHYSIC. 167

fever, I have seen a large evacuation by purging, of
mischievous consequence; and if upon occasion, a more
moderate evacuation has appeared to be useful, it is ap-
prehended to have been only by taking off the irrita-
tion of retained faeces, or by evacuating corrupted hu-
mours, which happened to be present in the intestines;
for both of which purposes, frequent laxatives may be
properly employed.

150. Another set of means (127. 2.) for moderating
the violence of reaction in fevers, are those suited to
take off the spasm of the extreme vessels, which we be-
lieve to be the irritation that chiefly supports the reac-
tion.*

Though I have put here this indication of taking off
the spasm of the extreme vessels, as subordinate to the
general indication of moderating the violence of reac-
tion; it is, however, to be observed here, that as fever
universally consists in an increased action of the heart,
either in frequency or in force, which in either case is
supported by a spasm of the extreme vessels, so the in-
dication for removing this is a very general one, and ap-
plicable in almost every circumstance of fever, or at

* Cutaneous secretion, or, as it is more commonly termed, perspiration, is
a natural function ; and, as it is checked or suspended in most cases of fever,
ought to be restored ; which is, perhaps, all that, in reality, Dr. Cullen
meant by " taking off the spasm of the extreme vessels." So far, therefore,
his indication is correct and natural. Nor have we any material fault to find
with his means of effecting it ; but his reasoning as to their modus operandi is
altogether mechanical and unsatisfactory.

The excitement of perspiration is a vital sympathetic process ; not a gross
mechanical one, depending on a mere distention of the blood-vessels. The
articles exhibited for the purpose act on the stomach, and produce an asso-
ciated action of the cutaneous capillaries. By a plentiful draught of some
warm liquid, when the body is cool, or of cold water alone, when it is heated,
a perspiration is oftentimes produced too instantaneously, to be explicable
otherwise than on principles of sympathy.

Balm and sage, mint and chamomile teas, taken in plentiful draughts, fre-
quently repeated, and of a temperature as high as may be agreeable to the
sick, are exceedingly useful in promoting a perspiration; the more so, per-
haps, on account of the slight aroma which they contain.

168 PRACTICE OF PHYSIC.

least, with a few exceptions, to be taken notice of here-
after.

151. For taking off the spasm of the extreme vessels,
the means to be employed are either internal or exter-
nal.

152. The internal means (151.) are,

1. Those which determine the force of the circula-
tion to the extreme vessels on the surface of the body,
and, by restoring the tone and activity of these vessels,
may overcome the spasm on their extremities.

2. Those medicines which have the power of taking
off spasm in any part of the system, and which are
known under the title of antispasmodics.

153. Those remedies which are fit to determine to
the surface of the body, are,

1. Diluents.

2. Neutral Salts.

3. Sudorifics.

4. Emetics.

154. Water enters, in a large proportion, into the
composition of all the animal fluids, and a large quantity
of it is always diffused through the whole of the com-
mon mass. Indeed, in a sound state, the fluidity of the
whole mass depends upon the quantity of water present
in it. Water, therefore, is the proper diluent of our
mass of blood; and other fluids are diluent only in
proportion to the quantity of water they contain.

155. Water may be said to be the vehicle of the seve-
ral matters which ought to be excerned; and in a healthy
state the fulness of the extreme vessels, and the quantity
of excretions, are nearly in proportion to the quantity of
water present in the body. In fever, however, although
the excretions are in some measure interrupted, they
continue in such quantity as to exhale the more fluid
parts of the blood ; and while a portion of them is at the

PRACTICE OF PHYSIC. J QQ

same time necessarily retained in the larger vessels, the
smaller and the extreme vessels, both from he deficiency
of fluid, and their own contracted state, are less filled,
and therefore allowed to remain in that condition.

156. To remedy this contracted state, nothing is more
necessary than a large supply of water or watery fluids,
taken in by drinking or otherwise; for as any superflu-
ous quantity of water is forced off by the several excre-
tories, such a force applied, may be* a means of dilating
the extreme vessels, and of overcoming the spasm af-
fecting their extremities.

157. Accordingly the throwing in of a large quantity
of watery fluids has been, at all times, a remed) much
employed in fevers; and in no instance more remarka-
bly than by the Spanish and Italian physicians, in the
use of what they call the Diceta aquea.

158. This practice consists in taking away every other
kind of aliment and drink, and in giving in divided por-
tions every day, for several days together, six or eight
pounds of plain water, generally cold, but sometimes
warm. All this, however, is to be done only after the dis-
ease has continued for some time, and, at least, for a week.

159. A second means (153. 2.) of determining to the
surface of the body, is by the use of neutral salts. These,
in a certain dose taken into the stomach, produce, soon
after, a sense of heat upon the surface of the body; and,
if the body be covered close and kept warm, a sweat is
readily brought out. The same medicines, taken during
the cold stage of a fever, very often put an end to the
cold stage, and bring on the hot ; and they are also re-
markable for stopping the vomiting which so freqis.'itly
attends the cold stage of fevers. All this shows, that
neutral salts have a power of determining the blood to
the surface of the body, and may therefore be of use
in taking off the spasm which in fevers subsists there.

vol. i. y

170 PRACTICE OF PHYSIC.

160. The neutral most commonly employed in fevers,
is that formed of an alkali with the native acid of vege-
tables; but all th other neutrals have more or less of
the same virtue; and perhaps some of them particularly
the ammoniacal salts, possess it in a stronger degree.*

161. As cold water taken into the stomach, often
shows the same diaphoretic effects with the neutral
salts, it is probable that the effect of the latter depends
upon their refrigerent powers mentioned above, (134.)
What is the effect of the neutral salts, given when they
are forming and in a state of effervescence? It is pro-
bable that this circumstance may increase the refrige-
rent power of these salts, and may introduce into the
body a quantity of fixed air; but for these purposes it
would seem proper to contrive that the whole of the
effervescence should take place in the stomach.

162. A third means (153. 3.) of determining to the
sulfa ce of the body, and taking off the spasm subsist-
ing there, is by the use of sudorific medicines, and of
sweating.

* Our author here alludes, most pmbably, to the neutral mixture formed by
the vegetable alkali saturated with lime juice, and to the spiritus Mindereri.
The former of these may be made to consist of the following proportions of
the ingredients :

R. Alkali. Vegetabil 9'i
Succ Limon 5ss.
Aquae Font. 3iss.
M f haust.

This, if swallowed while in the act of effervescence, and repeated at pro-
per intervals — say every hour or ofiener if necessary — is more remarkable
for its anti-emetic than its sudorific effects.

The Spts Minderer. consists of a saturated solution of muriate of ammonia
in distilled vinegar. When administered every two hours, in half-ounce
doses diluted in water, it is deemed efficacious in th.- excitement of a per-
spiration. Compared, however, with certain others, we believe it to be a
weak and inefficient remedy It is therefore that we have rarely employed
it in practice. If, during the use of it, the body be kept cool, it has the re-
putation of proving an active diuretic. To produce any medicinal effect, it
must be taken m such doses as to be felt in the stomach : for, like other in-
ternal remedies, it operates only through, the sympathies of that organ.

PRACTICE OF PHYSIC. 171

163. The propriety of this remedy has been much
disputed; and specious arguments may be adduced
both for and against .this practice.* >

In favour of the practice it may be said,

1. That, in healthy persons, in every case of increas-
ed action of the heart and arteries, a sweating takes
place and is seemingly the means of preventing the bad
effects of such increased action.

2. That, in fevers, their most usual solution and ter-
mination is by spontaneous sweating.

3. That, even when excited by art, it has been found
manifestly useful, at certain periods, and in certain
species of fever.

164. Upon the other hand, it may be urged against
the practice of s wealing,

1. That as in fevers a spontaneous sweating does not
immediately come on, so there must be in these some
circumstances different from those in a state of health,
and which may therefore render it doubtful whether
the sweating can be safely excited by art.

2. That in many cases, the practice has been attend-
ed with bad consequences. The means commonly em-
ployed have a tendency to produce an inflammatory
diathesis; which, if not taken off by the sweat following
their use, must be increased with much danger. Thus,
sweating employed to prevent the accessions of inter-
mitting fevers, has often changed thein into a conti-
nued form, which is always dangerous.

3. The utility of the practice is further doubtful, be-

* A forced sweat but rarely does good, and is oftentimes productive of
much exhaustion and distress. To be really useful it must flow somewhat
spontaneously; at least with facility. If the practitioner, therefore, find
much d'fficulty in exciting a sweat, he had better, for the time, relinquish
the attempt. His persevering efforts will exhaust his patient rather than
the disease.

172 PRACTICE OF PHYSIC.

cause sweating, when it happens, does not always give
a final determination; as must be manifest in the case
of intermittens, as well as in many continued fevers,
which are sometimes in the beginning attended with
sweatings that do not prove final; and. on the contrary,
whether spontaneous or excited by art, seem often to
aggravate the disease

165. From these considerations, it is extremely
doubtful if the practice of sweating can be admitted
very generally but at the same time, it is also doubtful,
if the failure of the practice, or the mischiefs said to
have arisen from it, have not been owing to the impro-
per conduct of the practitioner. With respect to this
last, it is almost agreed among physicians,

1. That sweating has been generally hurtful, when
excited by stimulant, heating, and inflammatory medi-
cines.

2. That it has been hurtful, when excited by much
external heat, and continued with a great increase of
the heat of the body.

3. That it is always hurtful, when it does not soon
relieve, but rather increases, the frequency and hard-
ness of the pulse, the anxiety and difficulty of breath-
ing, the headach, and delirium.

4. That it is always hurtful, if it be urged when the
sweat is not fluid, and when it is partial, and on the
superior parts of the body only.

166. In these cases, it is probable, that either an in-
flammatory diathesis is produced, which increases the
spasm on the extreme vessels; or that, from other causes,
the spasm is too much fixed to yield easily to the in-
creased action of the heart and arteries; and, upon
either supposition, it must be obvious, that urging the
sweat, as ready to produce a hurtful determination to

PRACTICE OF PHYSIC. 173

uome of the internal parts, may be attended with very
great danger.

167. Though the doubts started (164.) are to be at-
tended to; and although the practices (165.) having been
found hurtful, are therefore to be rejected; it still re-
mains true,

1. That sweating has certainly been often useful in
preventing the accession of fevers, when the times of
this have been certainly foreseen, and a proper conduct
employed.

2. That, even after fevers have in some measure
come on, sweating, when properly employed, either at
the very beginning of the disease, or during its ap-
proach and gradual formation, has often prevented their
further progress.

.3. That, even after pyrexias have continued for some
time, sweating has been successfully employed in cur-
ing them, as particularly in the case of rheumatism.

4. That certain fevers, produced by a very powerful
sedative contagion, have been generally treated, so far
as we yet know, most successfully by sweating.

168. These instances (167.) are in favour of sweat-
ing, but give no general rule; and it must be left to fur-
ther experience to determine how far any general rule
can be established in this matter. In the mean time, if
the practice of sweating is to be attempted, we can vem
tiSre to lay down the following rules for the conduct of it.

1. That it should be excited without the use of sti-
mulant inflammatory medicines.

2. That it should be excited with as little external
beat, and with as little increase of the heat of the body,
as possible.

3. That when excited, it should be continued for a
due length of time, not less than twelve hours; and
sometimes for twenty-four or forty-eight hours; always.

174 PRACTICE OF PHYSIC.

however, providing that it proceeds without the circum-
stances mentioned, (165. 3. 4.)*

4. That for some part of the time, and as long as Hie
person can easily bear, it should be carried on without
admitting of sleep.

5. That it should be rendered universal over the
whole body; and, therefore, particularly, that care be
taken to bring the sweating to the lower extremities.

6. That the practice should be rendered safer by
moderate purging, excited at the same time.

7. That it should not be suddenly checked by cold
any how applied to the body.

169. When attention is to be giren to these rules, the
sweating may be excited, 1. By warm bathing, or a
fomentation of the lower extremities. 2 By frequent
draughts of tepid liquors, chiefly water, rendered more
grateful by the addition of a light aromatic, or more
powerful by that of a small quantity of wine. 3. By giv-
ing some doses of neutral salts. 4. Most effectually, and
perhaps most safely, by a large dose of an opiate joined
with a portion of neutral salts, and of an emetic.

In what cases may cold water, thrown into the sto-
mach in large quantities, be employed to excite sweat-
ing? See Celsus, Lib. III. Chap. vii. — ix.

170. The fourth means (153. I.) of determining to
the surface of the body, and thereby taking off the spasm
affecting the extreme vessels, is by the use of emetics.

171. Emetics, and particularly antimonial emetics,
have been employed in the cure of fevers ever since the
introduction of chemical medicines: but for a long
time, they were employed by chemists and chemical

* To continue a sweat for " forty-eight hours," permitting the patient to
sleep but very little during that period, as must necessarily be the case,
I would be an unreasonable, harsh, and injurious practice. Such a measure
will not, we believe, find, at present, a single advocate.

PRACTICE OF PHYSIC. J 75

practitioners only: and although of late the use of them
has become very general, their efficacy is still disputed,
and their manner of operating is not commonly explained.
172. Vomiting is, in many respects, useful in fevers;
as it evacuates the contents of the stomach; as itemulges
the biliary and pancreatic ducts: as it evacuates the
contents of the duodenum, and perhaps, also, of a larger
portion of the intestines; as it agitates the whole of the
abdominal viscera, expedes the circulation in them,
and promotes their several secretions; and lastly, as
agitating also the viscera of the thorax, it has like effects
there. All these several effects are, in many cases and
circumstances of fever, procured with advantage; but
do not properly fall under our view here, where we are
to consider only the effect of vomiting in determining to
the surface of the body.*

* Our author's observations on emetics are pertinent and proper. The
effects of these remedies, in procuring a solution of fever, is oftentimes ob-
vious.

We do not believe, however, with the professor, that their action on the
stomach is confined chiefly to its " muscular fibres." It seems probable,
that they act more particularly on its nerves. It is certain, at least, that their
operation on that organ does not consist in their mere evacuation of its
contents ; but, that by severely stimulating it, they act on the skin and other
parts of the system, through the medium of its sympa-thies. The extent
and suddenness oi their effects admit of no explanation on any other prin-
ciple.

When administered only in nauseating closes, they produce their general
affects in the same way. Our author's remarks on this mode of exhibiting
them are judicious and worthy of attention. So are his remarks on the kinds
of these remedies that may be most advantageously employed.

In the United States, Dover's and James' powders are not much used.
They do not operate with so much certainty as tartar emetic or ipecacuanha,
under proper management.

To produce a nausea, the former of these may be administered in doses
varying from the sixteenth to the fourth of a grain, according to the age,
and state of the stomach, of the patient; and repeated every hour

Of the former, from half a grain to two grains may be exhibited at the
same intervals ; and, when combined with a little opium and prepared chalk,
we have not found its emetic quality particularly troublesome.

If the object be to produce the nauseating effect of tartar emetic, it may
be usefully exhibited under the following formula.

176 PRACTICE OF PHYSIC

173. This effect we do not impute to the exercise of
vomiting in agitating the whole frame; but to the par-
ticular operation of emetics upon the muscular fibres
of the stomach, whereby they excite the action of the
extreme arteries on the surface of the body, so as
thereby effectually to determine the blood into these
vessels, remove the atony, and take off the spasm affect-
ing them.

1 74. That such is the power of emetics, will appear
from the several considerations mentioned above (44.);
and therefore, that they are remedies well suited to the
cure of fevers.

175. Emetics, for that purpose, are administered in
two different ways: that is, either in such doses as may
excite full and repeated vomitings; or in such doses as
may excite sickness and nausea only, with little or no
vomiting at all.

1 76. Full vomiting is best suited to the several pur-
poses mentioned, (112.) and is well suited to determine
to the surface of the body, so as thereby to obviate the
atony and spasm which lay the foundation of fever.
Thus vomiting, excited a little before the expected ac-
cession of the paroxysm of an intermittent, has been
found to prevent the paroxysm altogether. And it has
been observed also, that when contagion has been ap-
plied to a person, and first discovers its operation, a vo-
mit given will prevent the fever, which was otherwise
to have been expected. See Lind on Fevers and Infec-
tion.

R Antimonii Tartarisati gr. ij.
Aquae Cinnamom. simpl. §ij.
Aquae font. § vj.
M. f. Julep.
Of this, one or two table spoonfuls may be given to an adult every lioui
or oftener, according to circumstances. To children the dose must be less
in proportion to their age.

PRACTICE OF PHYSIC. 177

177. These are advantages to be obtained by excit-
ing vomiting at the first approach of fevers, or of the
paroxysms of fevers; and after fevers are formed, vo-
miting may also be employed to take off, perhaps en-
tirely, the atony and spasm, or at least to moderate
these, so that the fever may proceed more gently and
safely.

178. It is seldom, however, that vomiting is found to
produce a final solution of fevers; and after they are
once formed, it is commonly necessary to repeat the
vomiting several times; but this is attended with incon-
venience, and sometimes with disadvantage. The ope-
ration of full vomiting commonly soon ceases, and the
exercise of vomiting is often a debilitating power; and
therefore, when the vomiting does not remove the atony
and spasm entirely, it may give occasion to their recur-
ring with greater force.

179. For these reasons, after fevers are fully formed,
physicians have thought proper to employ emetics in
nauseating doses only. These are capable of exciting
the action of the extreme vessels, and their operation
is more permanent. At the same time, they often show
their power by exciting some degree of sweat, and their
operation is rendered more safe, by their commonly
producing some evacuation by stool.

180. Such are the advantages to be procured by nau-
seating doses of emetics; and it only remains to mention,
what are the medicines most fit to be employed in that
manner, what are the most proper times for exhibiting,
and what is the best manner of administering them.

181. The emetics at present chiefly in use, are Ipe-
cacuanha and Antimony.

The former may be employed for every purpose of
emetics, particularly those mentioned (172). It
likewise be employed, either iu larger or smaller doses,

vol. 1. z

178 PRACTICE OF PHYSIC.

for determining to the surface of the body; but, even in
very small doses, it so readily excites vomiting, as to be
with difficulty employed for the purpose of nauseating
only; and however employed, there is reason to believe
that its effects are less permanent, and less powerfully
communicated from the stomach to the rest of the sys-
tem than those of Antimony.

182. This, therefore, is generally preferred; and its
preparations, seemingly various, may all be referred to
two heads; the one comprehending those in which the
reguline part is in a condition to be acted upon by the
aciJs; and therefore, on meeting with the acids in the
stomach, becomes active; and the other comprehending
those preparations in which the reguline part is already
joined with an acid, rendering it active.

183. Of each kind there are great numbers, but not
differing essentially from one another. It will be enough
for us to compare the Calx Antimonii Nitrata of the
Edinburgh Dispensatory with the Emetic Tartar of the
same. The former, as I judge, is nearly the same with
what is called James's powder. Which of these is best
suited to the cure of fevers, as above explained, seems
doubtful; but it appears to me. that, although the for-
mer may have some advantages from its slower opera-
tion, and may thereby seem to be more certainly sudo-
rific and purgative, yet the uncertainty of its dose ren-

t ders it inconvenient, has often given occasion to the
timid to be disappointed, and the bold to do mischief.
On the other hand, the dose of the Emetic Tartar can
be exactly ascertained; and I think it may be exhibited
in such a manner as to produce all the advantages of
the other.

1 84. Whichsoever of these preparations be employed,
I judge tiic most proper time for exhibiting them, to be
the time of accession, or a little before, when that can

PRACTICE OF PHYSIC. 179

be certainly known. In continued fevers, the exacerba-
tions are not always very observable; but there is rea-
son to think, that one commonly happens about noon, or
soon after it, and another in the evening; and that these,
therefore, are the most proper times for exhibiting eme-
tics.

185. With respect to the manner of administration,
that of the Calx Nitrata is simple, as the whole of what
is judged a proper dose is given at once, and no more
can properly be given till the time of the next acces-
sion.

The administration of the Emetic Tartar is different.
It is to be given in small doses, not sufficient to excite
vomiting; and these doses, after short intervals, are to
be repeated for several times, till sickness, nausea, and
some, but not much, vomiting, come on. The differ-
ence of this administration must depend upon the dose,
and the length of the intervals at which it is given. If
it be intended that the medicine should certainly ope-
rate by stool, the doses are made small, and the inter-
vals long. On the contrary, when vomiting is proper,
or when much purging ought to be avoided, and there-
fore some vomiting must be admitted, the doses are
made larger, and the intervals shorter.

186. With respect to both kinds of preparations, the
repetition is to be made, at the times of accession, but
not very often: for if the first exhibitions, duly ma-
naged, have little effect, it is seldom that the after exhi-
bitions have much, and it sometimes happens that the
repeated vomitings, and especially repeated purges, do
harm by weakening the patient.

187. The other set of internal medicines (152. 2.)
which I suppose may be useful in taking off the spasm
of the extreme vessels, are those named antispasmodic.

How many of these may be properly employed, I am

180 PRACTICE OF PHYSIC.

uncertain; and their mode of operation is involved in
great obscurity. It is certain, however, that opium,
camphor, musk, and perhaps some others, have been
employed in fevers with advantage; but the circum-
stances in which they are especially proper and safe, I
find difficult to ascertain; and therefore cannot venture
here to lay down any general doctrine concerning them.

188. The external means (151.) suited to take off the
spasm of the extreme vessels, are blistering and warm

BATHING.

189. What are the effects of blistering, so frequently
employed in fevers, is not yet agreed upon among phy-
sicians; and many different opinions have been main-
tained on this subject, drawn not only from reasoning,
but also from presumed experience. I must not, how-
ever, enter into controversy; but shall deliver my own
opinion in a few words.

190. I am persuaded, that the small quantity of can-
tharides absorbed from a blistering plaster, is not suffi-
cient to change the consistence of the mass of blood;
and therefore, that such a quantity can neither do good,
by resolving phlogistic lentor, if it exists; nor do harm,
by increasing the dissolution of the blood arising from
a putrid tendency in it. I therefore neglect entirely the
effects of cantharides upon the fluids.

191. The inflammation produced by the application
of cantharides to the skin, affords a certain proof of
their stimulant power; but in many persons, the effect
of that stimulus is not considerable; in many it is not
communicated to the whole system; and even when the
effect does take place in the whole system, it seems to
be taken off entirely, by the effusion and evacuation of
serum from the blistered part. I conclude, therefore,
that neither much good is to be expected, nor much
harm to be apprehended, from the stimulant power of

PRACTICE OF PHYSIC. Jgl

blistering; and the certainty of this conclusion is esta-
blished, by the great benefit arising from the proper
practice of blistering in inflammatory diseases.

192. Much has been imputed to the evacuation oc-
casioned by blistering; but it is never so considerable
as to affect the whole system; and therefore can neither,
by sudden depletion, relax the sanguiferous vessels, nor,
by any revulsion, affect the general distribution of the
fluids.

1 93. The evacuation, however, is so considerable as
to affect the neighbouring vessels; and the manifest uti-
lity of blistering near the part affected, in inflammatory
diseases, leads me to believe, that blistering, by deriv-
ing to the skin, and producing an effusion there, relaxes
the spasm of the deeper seated vessels. I apprehend it
to be in this manner, that the tumour of a joint, from
an effusion into the cellular texture under the skin, takes
off the rheumatic pain affecting that joint.

1 94. Analogous to this, it may be held, that the good
effects of blistering in continued fevers, arise from its
relaxing the spasm of the extreme vessels, by a com-
munication of the blistered part with the rest of the
skin ; and this is illustrated by the effect of blistering in
colic and dysentery.*

195. It appears to me, that blistering may be employ-
ed at any period of continued fevers; but that it will be

* The mere quantity of the serous evacuation produced by blisters, can
have no influence in their general effects. These, like other remedies, ope-
rate entirely through the medium of sympathy, resulting from a peculiar
local impression. They specifically stimulate the skin, on the spot to which
they are applied, and from that, as a point of beginning, forming a new
chain of associated actions, tend to dissolve the morbid one already exist-
ing. It is probable that blisters affect first, by what writers denominate
continuous sympathy, the whole, or a considerable portion of the skin ;
while that organ, by a very extensive and powerful range of sympathies,
which it is known to possess, more especially with the stomach, intestines,
and lungs, communicates somewhat of its own condition to the whole system.

182 PRACTICE OF PHYSIC.

of most advantage in the advanced state of such fevers,
when the reaction being weaker, all ambiguity from the
stimulant- power of blistering is removed, and when it
may best concur with other circumstances tending to a
final solution of the spasm.*

196. From the view of this matter given in (193. and
194.) it will appear, that the part of the body to which
blisters ought to be applied, is indifferent, excepting up-
on the suspicion of topical affection, when the blister-
ing ought to be made as near as possible to the part
affected. f

197. Whether sinapisms and other rubefacientia,
act in a manner analogous to what we have supposed of
blistering, may be doubtful; but their effects in rheuma-
tism, and other inflammatory diseases, render it probable.

198. The other external means of taking off the spasm
of the extreme vessels, is Warm Bathing. This was
frequently, and in various circumstances, employed by
the ancients; but till very lately has been neglected by
modern physicians. As the heat of the bath stimulates
the extreme vessels, and, with the concurrence of mois-
ture, also relaxes them, it seems to be a safe stimulus,
and well suited to take off the spasm affecting them.

* Blisters cannot be applied with advantage nor even with safety " at any
period of continued fevers." If they be applied during an early period,
when the morbid action is highly inflammatory, they cannot fad to do mis-
chief. They simply add the amount of their own stimulation to that under
which the system is already labouring ; and, by that means, augment the
force of febrile action. In cases of inflammatory fever, the lancet should
have nearly completed its duty, before blisters are called to theirs.

■j- The sentiment contained in this paragraph is not correct. In cases
where there is no apparent local affection, there exists, notwithstanding, a
clear choice, as to the parts of the body on which blisters should be applied.
The skin of the upper and lower extremity, especially of the wrists and an-
cles, appears to sympathize more strongly with the whole system than that
of any other pan of the body. As a general rule, therefore, on these situa-
tions, in continued fevers, let blisters be applied. We feel also persuaded
that blisters applied along the spine, act with peculiar energy on the system
in general.

PRACTICE OF PHYSIC. ]83

199. It may be applied to the whole body by immer-
sion; but this is, in man> respects, inconvenient; and
whether some of the inconveniences of immersion might
not be avoided by a vapour-bath, I have not learned
from experience. I know, however, from much experi-
ence, that most of the purposes of warm bathing can
be obtained by a fomentation of the legs and feet, if
properly administered, and continued for a due length
of time, which ought not to be less than an hour*

200. The marks of the good effects of such a fomen-
tation, are, the patient's bearing it easily, its relieving
delirium, and inducing sleep.

201. Having now considered the several means of
satisfying the first general indication in the cure of
fevers, I proceed to the second, ( 126.; which is, To re-
move the cause or obviate the effects of debilitij.

202. Most of the sedative powers inducing debility,
cease to act soon after they have been first applied; and,
therefore, the removing them is not an object of our
present indication. There is only one which may be
supposed to continue to act for a long time; and that is,
the contagion applied: but we know nothing of the na-
ture of contagion that can lead us to any measures for
removing or correcting it. We know only its effects as
a sedative power inducing debility, or as a ferment in-
ducing a tendency to putrefaction in the fluids. The
obviating the latter will be considered under our third
general indication, and the former alone is to be con-
sidered here.f

* A vapour bath, formed simply by wetting hot bricks with vinegar or
water, and placing them under the bed-clothes, has a powerful influence in
exciting a perspiration ; which is all that our author can mean, by a removal
of the spasm from the cutaneous vessels.

-j- For a knowledge of our sentiments on sedatives and putridity, the read-
er is referred to what we have said on former occasions. We shall, at pre-
sent, only add, that what is usually considered as a putrescent state of the

184 PRACTICE OF PHYSIC.

203. The debility induced in fevers by contagion, or
other causes, appears especially in the weaker energy
of the brain; but in what this consists, or how it may
be directly restored, we do not well know. As nature,
however, does, seemingly for this purpose, excite the ac-
tion of the heart and arteries, we ascribe the continuance
of debility to the weaker reaction of the sanguiferous
system; so that the means to be employed for obviating
debility, are immediately directed to support and in-
crease the action of the heart and arteries; and the
remedies used are tonics or stimulants.

204. In contagious diseases, both from the effects
which appear, and from dissections, it is known that
the tone of the heart and arteries is considerably di-
minished; and that tonic remedies, therefore, are pro-
perly indicated.

These are to be considered as of two kinds: the
first being the power of cold, the second that of tonic
medicines.

205. The power of cold, as a tonic, I have mention-
ed above; (90.) and it is employed, in fevers, in two

blood, preventing that fluid from coagulating when drawn from the veins, is
nothing more than its possessing too little vitality to enable it to contract as
it does when in a healthy condition Its escape from the small veins, form-
ing petechia:, vibices, and maculae, far from bespeaking in it any unusual
thinness, arises from the want of a sufficiency of the via vitx in those vessels
to qualify them to retain it. Instead of inspissants, therefore, or any kind of
correctives of the blood, the only proper remedies here, are tonics, or such
articles as communicate vital strength to the solid fibre.

The question, in this case, is not, whether the blood, when drawn from
the veins of a patient covered with vibices, will putrefy sooner than ii does
when taken from a person in health ? This it will certainly do, owing to its
destitution of the necessary stock of the vital principle, which is the most
powerful and efficient antiseptic in nature. The pathological point to be
settled is, whether that fluid, when circulating in its proper vessels, be in-
fected by any degree of a putrid taint? This we positively deny, and have
already referred to the authority (Dr. Sybert's Inaugural Dissertation) on
which, in part, our opinion is founded.

PRACTICE OF PHYSIC. 135

ways; either as the cold matter is thrown into the sto-
mach, or as it is applied to the surface of the body.

206. As it has been shown above, that the tonic
power of cold can be communicated from any one
par* to every other part of the system; so it will rea-
dily be allowed, that the stomach is a part as fit for
this communication as any other; and that cold drink,
taken into the stomach, may, therefore, prove an use-
ful tonic in fevers.

207. This the experience of all ages has confirmed;
but, at the same time, it has been frequently observed,
that, in certain circumstances, cold drink, taken into
the stomach, has proved very hurtful; and, therefore,
that the use of cold drink in fevers requires some limi-
tations. What these limitations should be, and what
are all the circumstances which may forbid the use of
cold drink, is difficult to determine; but it seems clear-
ly forbidden, in all cases where a phlogistic diathesis
prevails in the system, and more especially when there
are topical affections of an inflammatory nature.*

208. The other method of employing cold as a to-
nic, is, by applying it to the surface of the body. The
application of cold air to the surface of the body, as a
refrigerant power fit to moderate the violence of reac-
tion, I have spoken of above; (133.) but probably it
may also be considered here as a tonic, and useful in.
cases of debility.

* In relation to cold drinks, we believe that they never prove injurious in
febrile diseases, unless when taken at a temperature so low, or in quantities
so copious, as to prodace a sensation of chilliness. If an effect like this re-
sult from them, no matter whether the phlogistic or antiphlogistic diathesis
mark the disease, their use ought to be immediately discontinued. But if,
on the other hand, their employment be productive of pleasurable sensa-
tions, the continuance of them will be not only safe but advantageous In
this point of view, they may be considered as a tonic in fevers of a typhous
character, and a refrigerant in inflammatory ones.

vol. i. A a

186 PRACTICE OF PHYSIC.

209. Not only cool air, but cold water also, may be
applied to the surface of the body, as a refrigerant, and
perhaps as a tonic. The ancients frequently applied it
with advantage, to particular parts, as a tonic; but it
is a discovery of modern times, that in the case of pu-
trid fevers, attended with much debility, the body may
be washed all over with cold water.

210. This was first practised at Breslaw in Silesia,
as appears from a dissertation, under the title of Epide-
mia verna quce fVratislaviam, anno 1737, afflixit, to
be found in the appendix to the Acta. Nat. Cwios. Vol.
X. And from other writers we find, that the practice
has passed into some of the neighbouring countries; al-
though in this island, so far as I know, we have hitherto
had no experience of it.

211. The medicines which have been employed in
fevers, as tonics, are various. If the Saccharum Saturni
has been found useful, it is, probably, as a tonic, ra-
ther than as a refrigerant; and the Ens Veneris, or
other preparations of iron which have been employed,
can act as tonics only. The preparations of copper,
from their effects in epilepsy, are presumed to possess a
tonic power; but whether their use in fevers be founded
upon their tonic or their emetic powers may be uncertain.
The use of arsenic and of alum, in intermittent fevers,
seems manifestly to depend upon their tonic power.
And, upon the whole, there may occur cases of conti-
nued fevers, which may be cured by tonics taken from
the fossil kingdom; but the use of these has been rare,
as well as the effects uncertain; and physicians have
employed more commonly the vegetable tonics.*

* Preparations of copper and arsenic do not act as tonics in Uie cure of in-
termitting fever. They act as irritants or morbific stimuli. They produce ;>.
diseased impression on the stomach, stronger than that of marsh miasmata

PRACTICE OF PHYSIC. 187

212. A great variety of these has been employed in
the cure of intermittent fevers; but how many of them
may be employed in continued fevers, or in what cir-
cumstances of these fevers, is not well ascertained; and
I shall now only consider the question with respect to
the most celebrated of these tonics, the Peruvian Bark.

213. This bark has been commonly considered as a
specific, or as a remedy of which the operation was not
understood. But it is certainly allowable to inquire
into this matter; and I apprehend it may be explained.

214. To this purpose it may be remarked, that as,
in many cases, the effects of the bark are perceived
soon after its being taken in the stomach, and before it
can possibly be conveyed to the mass of blood, we may
conclude, that its effects do not arise from its operating
on the fluids; and must, therefore, depend upon its
operating on the nerves of the stomach, and being
thereby communicated to the rest of the nervous system.
This operation seems to be a tonic power, the bark
being a remedy in many cases of debility, particularly
in gangrene; and, as the recurrence of the paroxisms
of intermittent fevers depends upon a recurrence of
atony, (35. and 36.) so probably the bark,, by its tonic
power, prevents the recurrence of these paroxysms;
and this is greatly confirmed by observing, that many
other tonic medicines answer the same purpose.*

It is an impression, however, which will terminate in health, as soon as the
cause which gives rise to it is withheld.

If weunderst and the word tonic, it means a medicine that adds strength to
healthy action. Such, however, is not the effect of copper or arsenic As
far as our experience extends, these articles, instead of increasing healthy
action, never remove intermitting fever, until they have first very materially
disordered the stomach. Arsenic, in particular, produces a disease of that
organ perfectly svi generis, which entirely obliterates, for the time, the irri-
tation resulting from the cause of the malady it is intended to cure.

* The Peruvian bark is, perhaps, the most perfect, pure, and powerful
tonic belonging to the materia medica. It is never given, therefore, withou*
doing mischief, in cases where the phlogistic diathesis prevails.

188 PRACTICE OF PHYSIC.

215. If the operation of the bark mav be thus ex-
plained, from its possessing a tonic power, it is easy to
perceive why it is improper when a phlogistic diathesis
prevails; and from the same view, we can ascertain in
what cases of continued fever it may be admitted.
These are either after considerable remissions have
appeared, when it may be employed to prevent the re-
turn of exacerbations, on the same footing that it is
used in intermittent fevers, or in the advanced state of
fevers, when all suspicion of an inflammatory state is
removed, and a general debility prevails in the system;
and its being then employed is sufficiently agreeable to
the present practice.

216. With respect to the use of the bark, it is pro-

We believe, with Dr Cullen, that in curing fever, its immediate effects
are confined to the stomach. Were it to enter the lacteals, it would be as
crnle; were it to be carried into the blood-vessels, it would be in the form
of blood. In neither case would it be capable of producing a medicinal ef-
fect. A medicine, in the true sense of the word, is something which the
stomach cannot digest. This is the case with regard to the Peruvian bark.
That oryan cannot prepare it for the purposes of nourishment.

The bark, although it does not, like arsenic, greatly disorder the stomach,
produces in it, notwithstanding, a degree or mode of action peculiar to it-
self It is, in its effects, as perfect a specific, as mercury or cantharides,
asafoetida or opium. By its operation on the stomach, it changes entirely
the condition of that viscus, and obliterates the effect produced on it by the
febrile cause.

We consider it as a position almost self-evident, that those febrile diseases
which are particularly removed by the exhibition of the bark, have their
original seat in the stomach. It is because this local affection is in that or-
gan, and is not of an inflammatory character, that the remedy we are consi-
dering is calculated for its cure

Provided the stomach will retain it, the bark should be always given in
substance. The second best preparation is the extract ; and next to that the
decoction The tincture is not a very efficient remedy, and has often proved
injurious by inducing a fondness for ardent spirits.

Bark finely pulverized may be given in doses of a drachm weight, or a
heaped tea-spoonful, to be repeated every hour, or oftener according to cir-
cumstances. To those who prefer it in that way, it may be given in the
form of pills to the same amount.

PRACTICE OF PHYSIC. 189

per to add, that good effects are to be expected from
it, almost only when given in substance and in large
quantity.

217. Another set of Medicines to be employed for
obviating debility and its effects, are the direct stimu-
lants, (20:3.) These, in some measure, increase the
tone of the moving fibres; but they are different from
the tonics, as more directly exciting and increasing the
action of the heart and arteries. This mode of their
operation renders the use of them ambiguous; and when
an inflammatory diathesis is present, as so often hap-
pens in the beginning of fevers, the effects of these sti-
mulants may be very hurtful; but it still remains pro-
bable, that in the advanced state of fevers, when debi-
lity prevails, they may be useful.

218. What are the stimulants that may be most pro-
perly employed, I am uncertain, as the use of them in
this age has been rare; but I am disposed to believe
that, of all kinds, wine is the best.

2 1 9. Wine has the advantage of being grateful to the
palate and stomach, and of having its stimulant parts so
much diluted, that it can be conveniently given in small
doses; so that it may be employed with sufficient caution;
but it is of little service, unless taken pretty largely.

220. It may be supposed, and on good grounds, that
wine has an operation analogous to that of opium, and
some other narcotic medicines. It may indeed be said,
that we can distinctly mark its stimulant power only,
which renders its effects in the phrenitic delirium mani-
festly hurtful, and, in the mild delirium, depending on
d< bility, as remarkably useful. But in all this the ana-
logy with opium is still obvious; and it is probable, that
both wine and opium are more useful by their sedative
and antispasmodic, than by their stimulant powers.

221. These are the means of answering our second

190 PRACTICE OF PHYSIC.

general indication; (\2G. 2.) and I now proceed to the
third, which is, to obviate or to correct the tendency of
the fluids to putrefaction.

222. This may be done,

1. By avoiding any new application of putrid or pu-
trescent matter.

2. By evacuating the putrid or putrescent matter al-
ready present in the body.

3. By correcting the putrid or putrescent matter re-
maining in the body.

4. By supporting the tone of the vessels, and thereby
resisting further putrefaction, or obviating its effects.

223. The further application of putrid or putrescent
matter may be avoided,

1. By removing the patient from places filled with cor-
rupted air.

2. By correcting the air from which he cannot be re-
moved.

3. By preventing the accumulation of the patient's
own effluvia, by a constant ventilation, and by a frequent
change of bed-clothes and body linen.

4. By the careful and speedy removal of all excre-
mental matters from the patient's chamber.

5. By avoiding animal food, or correcting it*

224. The putrid or putrescent matter, already pre-
sent in the body, may be evacuated partly by evacuating
frequently the contents of the intestines, and more ef-

* The physicians of Europe, especially of Great Britain, speak in high
terms of the efficacy of nitro-muriatic acid gas in the purification of an in-
fectious or contagious atmosphere. It may be formed by pouring the nitric
acid on common salt. Having had no experience in the use of this article,
we are unable to speak of it from our own knowledge. We believe that
several physicians of the United States, who have employed it for depurat-
ing the atmosphere of ships of war, have been pleased with its effects.
Lime, in the way of white- washing, is much used for the same purpose.

We are inclined to think, that nature's own method, consisting in cleanli-
ness and free ventilation, constitutes the best purifying process. Wherever
it may be practicable, therefore, its adoption is recommended.

PRACTICE OF PHYSIC. \g\

fectually still, by supporting the excretions of perspira-
tion and urine, by the plentiful use of diluents.*

225. The putrid or putrescent matter remaining in
the body, may be rendered more mild and innocent by
the use of diluents, or may be corrected by the use of
antiseptics. These last are of many and various kinds;
but which of them are conveniently applicable, or more
particularly suited to the case of fevers, is not well as-
certained. Those most certainly applicable and useful,
are, acescent aliments, acids of all kinds, neutral salts
and fixed air.

226. The progress of putrefaction maybe considera-
bly retarded, and its effects obviated, by supporting the
tone of the vessels; and this may be done by tonic re-
medies; the chief of which are, Cold, and Peruvian
Bark, both sufficiently treated of above, (250. et seq.)

221. I have now finished the consideration of the
three general indications to be formed in the cure of
continued fevers, and have mentioned most of the re-
medies which have been, upon any occasion, employed
in this business. It was necessary, in the first place, to
consider these indications and remedies separately, and
to explain the operation of the latter more generally;
but from what has been now delivered, compared with
what was said above, concerning the difference of fe-
vers, and the signification of their several symptoms in
forming the prognostic, I expect it will not be difficult
to assign the indication, and to select and combine the
several remedies mentioned, so as to adapt them to the
several species and circumstances of continued fevers.

* As great prostration of strength constitutes one of the symptoms of
what is denominated putrid fever, purges should be used cautiously, lest de-
bility be injuriously increased. Injections and the milder purgatives ought
to be chiefly employed. In many instances of typhus fever, no inconsider-
able advantage is supposed to be derived from producing a constipation of
the bowels by the use of opium.

192 PRACTICE OF PHYSIC.

I think it may be useful for my readers to have the whole
of the cure of continued fevlrs brought under one
view, as in the following table.

IN THE CURE OF CONTINUED FEVERS,
THE INDICATIONS AUE,

I. To moderate the violence of reaction.
Which may be done by,

1. Diminishing the action of the heart and arteries, by
A. Avoiding or moderating those irritations which
are almost constant!) applied to the body; as,

a. The impressions made upon our senses, par-

ticularly,
«. Increased heat, whether arising from
ctot. External heat, or

js/3. The accumulation of the heat of the
. body.

b. The exercise of the body,

c. The exercise of the mind,

d. Taking in of aliment,

e. Particular irritations arising from
<*. The sense of thirst,

/3. Crudities, or corrupted humours, in the sto-
mach,
y. The preternatural retention of fasces,
£ A general acrimony of the fluids.
B Employing certain sedative powers; as,

a. Cold,

b. Refrigerants,- the chief of which are,
». Acids of all kinds,

/3. Neutral salts,
y. Metallic salts.
C. Diminishing the tension and tone of the arterial
system, by

a. Blood-letting,

b. Purging.

PRACTICE OF PHYSIC. 193

2. Taking off the spasm of the extreme vessels, by

A. Internal means; which are,

a. Those remedies which determine to the sur-

face, as,
*• Diluents,
P Neutral salts,
v- Sudorifics,
^ Emetics.

b. Those remedies named antispasmodics.

B. External means; as,

a. Blistering,

b. Warm bathing.

II. To remove the causes, or obviate the effects of de-

bility, by
1. Supporting and increasing the action of the heart
and arteries, by

A. Tonics, as,
a Cold,

b. Tonic medicines, which are either,
* Fossil, as,

**• Saccharum saturni, &c. or,
0- Vegetable, as,
<*<* Peruvian Bark.

B. Stimulants, as,

a. Aromatics, &,c.

b. Wine.

III. To obviate or correct the tendency of the fluids to

putrefaction, by
1. Avoiding the application of putrid or putrescent
matter, by

A. Removing the patient from places filled with
corrupted air.

B. Correcting the air from which he cannot be
removed.

vol. 1. Bb

194 PRACTICE OF PHYSIC.

C. Avoiding the accumulation of the patient's own

effluvia, by

a. A constant ventilation,

b. Frequently changing the bed-clothes and
body-linen.

D. Removing carefully and speedily all excremen-

tal matters.

E. Avoiding animal food, or correcting it.

2. Evacuating the putrid or putrescent matter already

present in the body, by

A. Evacuating frequently the intestines.

B. Supporting the excretions of perspiration and
urine, by

a. Diluents,

b. Neutral salts.

3. Correcting the putrid or putrescent matter remain-

ing in 'the body, by

A. Diluents,

B. Antiseptics,

C. Fixed air.

4. Resisting farther putrefaction, or obviating its ef-

fects, by
Supporting the tone of the vessels, by
Tonic remedies.

Sect. II. — Of the cure of Intermittent Fevers.*

228. It still remains to consider the cure of intermit-
tent fevers; and, with respect to these, we form also
three general indications.

* This section contains an excellent outline of the principles of practice
in intermitting fever. The indications of cure are judiciously laid down,
and the general modes of fulfilling them stated with great correctness and
skill. A brief exposition of one or two points which our author has omitted,
and a little further detail as to particular remedies, and the times and cir-

PRACTICE OF PHYSIC. 195

1. In the time of intermission, to prevent the recur-
rence nf paroxysms.

cumstances of their administration, is all, perhaps, that the article wants,
and all that our limits as an annotator permits us to subjoin.

We have already stated our belief, that intermitting fever has its seat
in the stomach. It arises from an irritating impression on that organ. What-
ever, therefore, during the state of apyrexia makes, on the same organ, a
counter-impression sufficiently powerful, and continues in it until after the
period at which the next paroxysm should commence, will prevent that
paroxysm. This it will do by its effect on the stomach alone, independently
of its action on the skin, the blood-vessels, or any other part of the system.
It shatters and destroys the very root of the disease, and hence the branches
must necessarily wither. It is in this way that all emetic articles act, as
well as the preparations of copper, arsenic, and opium. It is in the same
way that spirits of turpentine act, which, when given in large doses during
the intermission, has often proved effectual in checking intermittents; and
it is thus, also, that the bark itself acts ; for that remedy is known to pro-
duce little or no alteration in the state of the blood-vessels.

Indeed, it is necessarily in the same way that every internal remedy ope-
rates in the cure of intermittents. Medicines that act on the bowels are not
very useful in those diseases ; and whatever enters the lacteals is a medi-
cine no longer. Being completely subdued by the powers of digestion and
assimilation, it can be regarded only as an article of nutriment ; and, as such,
aids in continuing, not in altering the existing state of things.

When the subject is properly considered, the space in the human system
on which medicines, correctly so called, immediately act, is not very exten-
sive. It consists of the alimentary canal, the skin, the lungs, and that por-
tion of the Schneiderian membrane which lines the nares. To no other
parts can medical substances have immediate access. On these alone,
therefore, they act, and communicate their influence to other portions of
the body through the medium of sympathy.

It is true, that light stimulates the optic, and sound the auditory nerves :
and, in that way, operate somewhat as medicinal substances.

It is also true, that venesection acts immediately on the blood-vessels : but
this is a surgical operation, not a medicinal substance. It produces an un-
natural state of things ; penetrating through the skin by mechanical force,
in order to reach the parts that lie beneath it. Nor has venesection the
slightest tendency to show that any articles can carry their medicinal quali-
ties into the biood or humours of the body. Still, therefore, the truth re-
curs, that all medicinal substances, in common with all morbific ones, pro-
duce their first effect in the form of a local impression on the skin, the ali-
mentary canal, the lungs, or the nares, and extend their influence through
the medium of sympathy.

Impressions made on the stomach very soon reach the skin ; a truth
which we see daily confirmed by the occurrence of flushes, sweating, and
eruptions ; while those made on the latter organ as soon make their way to
the former, giving relief to sickness, nausea, and vomiting.

196 PRACTICE OF PHYSIC.

2. Tn the time of paroxysms, to conduct these so as to
obtain a final solution of the disease.

3. To take off certain circumstances which might pre-
vent the fulfilling of the two first indications.

229. The first indication may be answered in two
ways:

1. By increasing the action of the heart and arteries
some time before the period of accession, and support-
in? that increased action till the period of the accession
be over, so as thereby to prevent the recurrence of the
atony and spasm of the extreme vessels which give oc-
casion to the recurrence of paroxysms.

2. Without increasing the action of the heart and ar-
teries, the recurrence of paroxysms may be prevented,
by supporting the tone of the vessels, and thereby pre-
venting atony, and the consequent spasm.

230. For the purpose mentioned in 229. 1. the ac-
tion of the heart and arteries may be increased,

1. By various stimulant remedies, internally given, or
externally applied, and that without exciting sweat.

2. By the same remedies, or others so managed as to
excite sweating, and to support that sweating till the pe-
riod of accession h< fo some time past.

3. By nauseating doses of emetics, given about an
hour before the time of accession, thereby supporting
and increasing the tone and action of the extreme ves-
sels.

231. The tone of the extreme vessels may be sup-
ported without increasing the action of the heart and
arteries (229. 2.) by various tonic medicines; as,

1. Astringents alone.

Conscious that our views of the operation of medicines differ not a little
from those of many other writers, we have deemed it expedient to be thus
explicit in the statement of them, both in relation to the cure of intermitting
fever and other diseases.

PRACTICE OF PHYSIC. 197

2. Bitters alone.

3. Astringents and bitters conjoined.

4. Astringents and aromatics conjoined.

5. Certain metallic tonics.

6. Opiates.

Lastly, an impression of horror.

A good deal of exercise, and as full a diet as the con-
dition of the patient's appetite and digestion may allow
of, will be proper during the time of intermission, and
may be considered as belonging to this head*

* If an intermittent prove intractable to other remedies, let the patient,
if an adult, take from two to three grains of opium, either alone or com-
bined with two grains of ipecacuanha, or a quarter of a grain of tartar emetic,
about two hours before the commencement of an expected paroxysm. Let
him, further, go immediately to bed, and attempt the excitement of a sweat
by the application of heated bricks, or bottles of warm water, to his feet and
legs, and repeated draughts of sage or balm tea, or some other warm and
grateful beverage. If a copious sweat appear, which rarely fails to be the
case, let it be continued until the expiration of the third or fourth hour after
the time at which the paroxysm should have commenced. By this process
we have very seldom failed to prevent the paroxysm, which leads with cer-
tainty to a removal of the disease.

If horror be the remedy employed, it is of very little consequence in what
manner it is excited. Ignorant persons and children have been cured of
their complaint by being shut up in a dark room, in a house believed to be
haunted, and assailed by certain unusual sounds, for the space of an hour
before and after the time of an expected paroxysm.

A slave, some years ago, was cured of intermitting fever, in the state of
Delaware, by being taken to a certain spot to dig for money believed to have
been deposited there by the pirate Blackbeard. A negro was reported to
have been buried alive by the pirate along side of the chest, with orders to
keep watch over it and its contents until he should reclaim them.

Our patient, while digging, was under a constant apprehension of seeing
this sentinel start from the ground in defence of the treasure confided to his
keeping. Such were the impressions of horror which he experienced from
this fancy, that the expected paroxysm of his intermittent was prevented.

The same effect has been obtained by inducing patients of the same de-
scription to lie down on a tomb-stone, and muttering over them pretended
ceremonies of incantation.

It is on the same principle that charms, of whatever kind they may be,
operate to the cure of intermitting fever. They forcibly impress the mind:
this, through the medium of the brain, communicates its impression to the
stomach ; and thus the morbid irritation on that organ, which constitutes
the root of the disease, is counteracted.

198 PRACTICE OF PHYSIC.

232. Of all the tonic remedies mentioned (531.) the
most celebrated, and perhaps the most certainly effectual,
is the Peruvian bark, the tonic power of which we have
endeavoured to demonstrate above, (214.) and have, at
the same time, explained its use in continued fevers.

The same observation as made in 216, is especially
proper in the case of intermittents; and further, with
respect to these, the following observations or rules are
offered here.

1 . That the bark may be employed with safety at any
period of intermittent fevers, providing that, at the same
time, there be neither a phlogistic diathesis prevailing
in the system, nor any considerable or fixed congestion
present in the abdominal viscera.

2. The proper time for exhibiting the bark in inter-
mittent fevers, is during the time of intermission ; and
where intermissions are to be expected, it is to be ab-
stained from in the time of paroxysms.

3. In remittents, though no entire apyrexia occurs,
the bark may be given during the remissions; and it
should be given, though the remissions be inconsidera-
ble, if from the known nature of the epidemic, intermis-
sions, or considerable remissions are not to be soon
expected, and that great danger is apprehended from
repeated exacerbation.

4. In the case of genuine intermittents, while a due
quantity of bark is to be employed, the exhibition of it
ought to be brought as near to the time of accession as
the condition of the patient's stomach will allow.

5. In general, in all cases of intermittents, it is not
sufficient that the recurrence of paroxysms be stopped
for once by the use of bark; a relapse is commonly to
be expected, and should be prevented by the exhibition
of the bark repeated at proper intervals*

* The propriety of giving an emetic, as preparatory to the administratien

PRACTICE OF PHYSIC. 199

233. Our second general indication for conducting
the paroxysms of intermittent fevers, so as to obtain a
final solution of the disease, may be answered,

of the bark, is a practical question, which, however frequently agitated,
does not appear to be definitively settled.

The measure, although not in all cases essential to a cure, we believe to
be in most instances highly useful. Besides their tendency to remove from
the stomach the topical affection, which we consider as the source of inter-
mitting fever, emetics discharge from that organ all such adhesive matters
as might interpose beiween the bark and its internal surface. They procure
for that article a more immediate access to its villous coat, and thereby add
to the efficacy of its action. By exciting, moreover, the necessary action on
the surface of the body, they render the bark a safer remedy: for, to ad-
minister that medicine when the skin is dry, is a practice that is not war-
ranted by experience.

On the whole, therefore, although many cases of intermitting fever are
cured by the bark alone, without the previous administration of an emetic,
we are inclined to believe, that, as a general rule, the reverse is the safer and
more efficacious practice.

A few doses of the vegetable alkali are said to be an excellent substitute
for an emetic. This article is supposed to dissolve the mucus adhering to
the internal surface of the stomach, which an emetic would eject, and in that
way to bring the bark into immediate contact with its villous coat.

In the treatment of intermitting fever, all agree that the bark must be
administered during the period of apyrexia: but there exists a difference of
opinion as to the particular time of that period, at which it should be given
in the largest quantity. Dr. Cullen says, towards the close— as near as pos-
sible to the commencement of the next expected paroxysm.

In this mode of practice we confess there appears to be not a little reason.
By means of it the strongest impressions would seem to be made by the
bark on the stomach at that point of time when it is best calculated to keep
off the irritation which causes the disease. As opium is known to prevent
a paroxysm with most certainty when administered only a short time before
its commencement, why is not the same thing true with regard to the bark?

Alibert, on the other hand, in his excellent treatise on » Malignant Inter-
mittents," asserts, that the bark should be given at as great a distance of
time as possible from the next expected paroxysm. His practice was, there-
fore, to exhibit it in large and frequent doses at the commencement cf the
apyrexia, instead of the close ; and, according to his own account, his suc-
cess was signal.

This mode of practice is not without both argument and example in its
favour.

The bark is not what is denominated a diffusible stimulus. It does not
operate so speedily as opium ; and. therefore, to produce the necessary
effect, must be given at a greater length of time before its highest degree of
action is wanted. Hence, although opium prevents a paroxysm, when ad-
ministered only two hours before the time of its expected occurrence, bark,

200 PRACTICE OF PHYSIC.

1. By exhibiting emetics during the time of the cold
stage, or at the beginning of the hot.

to produce the same effect, may require to be given at a much earlier
period — twelve, perhaps even twenty-four hours before the time of the
anticipated attack Besides, it is very well known, that the preparations of
iron, copper,and arsenic, must be exhibited a very considerable time before
thev produce the full amount of their action on the system

To avail ourselves of every advantage, our own practice with the bark has
been, to give it from the beginning to the close of the apyrexia, in doses as
large and as frequently repeated as the stomach will retain In some cases we
have administered, with perfect success, from a drachm to a drachm and a
half every hour, until three ounces have been used

Alibert and others have practised in a manner still bolder To that phy-
sician's treatise on ** Malignant Intermittents," we refer our readers for
much useful information respecting those complaints.

When the bark disagrees with the stomach, or fails to cure the disease, it
mav be advantageously combined with certain spices, or other aromatic and
stimulating substances. In such cases, cloves, ginger, pepper, particularly
Cayenne pepper, and Virginia snake root, finely pulverized, have been
found particularly useful Of the four first articles, from three to six, and of
the last from ten to fifteen grains may be added to each dose of the bark.
Five or six drops of the elixir of vitriol may be also added with the same in-
tention.

Does the bark purge ? combine with each dose of it five drops of lauda-
num. Does it create costiveness ? add to each dose an equal number of
grains of rhubarb.

If, under every form of preparation, the bark fail to cure, give of white ar-
senic the sixteenth of a grain, combined with a grain or two of ginger four
or five times a day ; or, of the same article, in the form of Fowler's solution,
about six drops as often repeated.

Cuprum vitriolatum and cuprum ammoniacum, in doses of one fourth of a
grain, repeated three or four times a-day, have been also found successful in
cases of intermittents that had resisted other remedies.

It is in the treatment of the quartan ague, that these three last remedies
have been most successfully employed.

A remedy now becoming fashionable in Great Britain, in the cure of this
complaint, and said to be efficacious beyond all others, is the spider's -web, in
doses of from two to four grains. If taken during the paroxysm, it shortens
it; if before it, prevents it.

It is said that no intermittent resists more than two or three repetitions of
it. It is usually administered in the form of a pill, a short time previously to
the expected attack. The species of spider whose web is most efficacious
we are unable to designate.

Another article which, in the cure of intermittents, has received conside-
rable reputation abroad, and has also been successfully used, in some in-
stances, in this eountry, is finely powdered charcoal The dose for an adult
is a table-spoonful, to be repeated several times a-day.

PRACTICE OF PHYSIC. 201

2. By opiates given during the time of the hot stage.

234. The circumstances which may especially pre-
vent the fulfilling of those two indications, and there-
fore give occasion to our third, are a phlogistic diathe-
sis prevailing in the system, and congestions fixed in the
abdominal viscera. The first must be removed by
blood-letting and the antiphlogistic regimen ; the second
by vomiting and purging.

Where these measures are not immediately effectual,
I hold it safer to attempt the cure of the disease by the
means pointed out in general in 229, rather than by .
those in article second of the same parag ph.

The application of tourniquets on the thigh and arm of the opposite sides,
obstructing the circulation of the blood, some time before the period of the
expected paroxysm, is said to prove effectual in its prevention. In this
practice we have had no experience.

In the treatment of this disease, some of our own indigenous remedies are
worthy of more attention than they usually receive.

Of these, we may mention, in particular, the Virginia snake-root, the herb
centaury, the bark of the dogwood, (both species,) the bark of the willow,
and that of the root of the liriodendron tulipifera, commonly denominated
the American poplar.

These articles are sometimes used in the form of decoction : but they are
most efficacious when administered in substance in the same mode, and in
nearly the same doses, with the Peruvian bark.

In some parts of the country, these remedies are much used by the inhar
bitants, without medical advice : and, unless where the disease proves un-
commonly obstinate, rarely fail to effect its removal.

Cases of intermittents that had baffled every thing else, have yielded, at
length, to a change of situation, climate, or season, or a change in the con-
stitution of the patient in his advancement in years.

VOL. I. CC

200 PRACTICE OF PHYSIC.

BOOK II.

OF INFLAMMATIONS,

OR PHLEGMASIA.

CHAPTER I.

OF INFLAMMATION IN GENERAL.
Sect. I. — Of the Phenomena of Inflammation.

235. AV^HEN any part upon the surface of the body is
affected with unusual redness, heat, pain, and tumour,
we name the disease an Inflammation or Phlegmasia.
These symptoms of inflammation are never considera-
ble, without the whole system being, at the same time,
affected with pyrexia.

236. As the external, so likewise the internal parts
may be affected with inflammation, and we judge them
to be so, when, together with pyrexia, there is a fixed
pain in any internal part, attended with some interrup-
tion in the exercise of its functions.

237. We judge of the presence of inflammation also
from the state of the blood drawn out of the veins. When
the blood, after cooling and concreting, shows a portion
of the gluten separated from the rest of the mass, and
lying on the surface of the crassamentum ; as such sepa-
ration happens in all cases of more evident phlegmasia;
so, in ambiguous cases, we, from this appearance, joined
with other symptoms, infer the presence of inflammation.
At the same time, it must be observed, that as several

PRACTICE OF PHYSIC. 203

circumstances in blood-letting may prevent this separa-
tion of gluten from taking place in blood otherwise dis-
posed to it; so, from the absence of such appearance,
we cannot always conclude against the presence of in-
flammation.*

238. I cannot easily give any other general history of
the phenomena of inflammation than what is contained
in the three preceding paragraphs ; and the variations
which may take place in its circumstances, will occur

* Blood exhibits an inflammatory or sizy covering, somewhat in propor-
tion to the slowness of its coagulation. If it coagulate very slowly, this
covering will be conspicuous ; if less slowly, less conspicuous ; and if it
coagulate rapidly, it will not be formed at all.

Blood, again, coagulates with a rapidity somewhat proportioned to the
slowness with which it is drawn from the vein. If it be drawn off in a very
small stream, but more especially by drops, it coagulates almost as soon as
it falls into the vessel in which it is received. But if it be made to flow in
a full and bold stream, it does not coagulate for a considerable time. Other
circumstances, therefore, being alike, it may, in the latter case, exhibit a
sizy covering, but not in the former.

In general, blood drawn guttatim, or in a very small stream, rarely exhi-
bits a thick inflammatory coat : whereas that which flows in a free stream
exhibits it frequently.

The form of the vessel also, in which blood is received, makes no incon-
siderable difference in the appearance of the coagulum If it be wide, flat,
and shallow, the blood coagulates rapidly, and throws up very little buff;
but if deep and narrow, it coagulates slowly, and throws up more.

The blood of a person in perfect health, by being drawn in a free stream,
received into a narrow vessel, and placed in an atmosphere of a low tempe-
rature, may be made to coagulate so slowly, as to exhibit a sizy coat of con-
siderable thickness : while, on the contrary, that of a patient labouring under
an inflammatory disease, by being differently treated, will manifest no size.

The theory of the formation of the sizy covering of blood appears to be as
follows.

That fluid is known to consist of three parts, the coagulating lymph, the
serum, and the red globules, of which the latter are the heaviest in propor-
tion to their bulk.

If the blood coagulate immediately after being drawn from the vein, the
coagulating lymph, in contracting, arrests the red globules, and holds them
so intimately mingled with itself, as to exhibit an appearance uniformly
florid. But if it be longer in coagulating, the red globules, being the
weightiest portion, sink towards the bottom of the vessel, while the- blood is
yet liquid, leaving the white or buff coloured lymph at the top. This lymph
coagulating, forms the sizy covering of which we are speaking.

204 PRACTICE OF PHYSIC.

to be more properly taken notice of under the several
heads of the particular genera and species to be hereaf-
ter mentioned. I proceed, therefore, to inquire into the
proximate cause of inflammation in general.

Sect. II. — Of the Proximate Cause of Inflammation*

239. The phenomena of inflammation (235.) all con-
cur in showing that there is an increased impetus of
the blood in the vessels of the part afFected; and as, at

• Dr. Cullen's theory of inflammation is confused and unsatisfactory. Be-
ing, much of it, conjectural, and, as a whole, altogether incompetent to ex-
plain the phenomena of the disease ; it is now, we believe, abandoned by
every pathologist. Instead, therefore, of a useless display of argument
against an hypothesis which no longer misleads the minds of physicians, we
think it better to lay before our readers as succinct a view as possible, of
what appears to us to be the least objectionable theory of inflammation. We
say the least objectionable, for it must be acknowledged that there still exist
objections to every theory.

Instead of being " increased," it appears from experiment, and we think
also from reason, that the " impetus of the blood" in an inflamed part is
necessarily diminished. On no other ground can the leading and character-
istic phenomena be explained.

A congestion of blood in the vessels of the part affected, constitutes an
essential condition of ever}' inflammation. It is a fundamental symptom,
without which the disease can have no existence, in as much as it operates
as the cause of other symptoms.

But without a diminished impetus — a remora or obstruction of some kind —
no topical congestion can take place ; much less can it occur under an in-
creased impetus. Were the impetus in every part of the vessels the same,
the blood would be equally diffused throughout the whole : were it in any
part increased, the blood would appear in that part in a diminished propor-
tion. From the very nature of the case, the impetus and the quantity of
blood in any^ given part, must always maintain towards each other an inverse
ratio : if the impetus be preternaturally great, the quantity will be preter-
naturally small, and the reverse.

For the illustration of our position we will resort to a comparison. The
current of the blood through the veins is aptly enough represented by the
current of a river within its banks. They both consist of a fluid in motion.
In what part of a river, then, are we accustomed to find an accumulation of
its waters? Surely not at its rapids, where the impetus of the water is in-
creased, and the stream, of course, preternaturally shallow ; but at some flat
and level spot, where their impetus is weak and their movement sluggish :
it is there alone, that, within a given space, the waters exist in a supera-
bundant quantity.

PRACTICE OF PHYSIC. 205

the same time, the action of the heart is not always evi-
dently increased, there is reason to presume, that the

Bat as well might we expect to find an accumulation of water within the
declivity of the rapids of a river, as a congestion of blood in any portion of
the vessels where its impetus is increased.

Thus far does reason support us in our position. Nor is the result of
experiment and observation less favourable to us. When examined with a
microscope, the movement of the blood through the vessels of an inflamed
part i3 found to be preternaturally slow. In cases of great violence it is
scarcely perceptible. So stagnant does the blood become in these instances,
as to exchange its arterial for a venous character, communicating to the part
affected somewhat of a purple instead of a florid colour. So far is the im-
petus of the blood, then, from bearing a direct proportion to the violence of
inflammation, that the reverse is true — the inflammation is high in proportion
as the remora is great and obstinate. Hence a purplish appearance, in
topical inflammation, gives reason to apprehend an approaching gangrene.

Again : the nature of the causes which induce inflammation, is such as
convinces us that they diminish rather than increase the powers of action
in the part affected. As far as we know and can speak of them with cer-
tainty, they are cold, mechanical violence, and chemical irritants. Under
the latter head we include burning, or the action of fire.

But neither of these can produce inflammation until it has so far injured
the part affected, as necessarily and very obviously to diminish its powers.
On no principles whatever can the long continued application of intense cold,
a severe contusion, or a wound, be supposed to add to the powers of action
in the injured part. On the other hand, the patient himself is sensible, at
the time, of the reduction of these powers — sensible that the functions of
the part are weakened. The same thing may be said with regard to the ap-
plication of fire. More promptly and certainly, perhaps, than any thing
else, does it diminish the powers of action. For the truth of this, we can-
not do better than refer to the experience of those who have been subject
to the injuries of which we are speaking. Besides, had we a wish to invi-
gorate the powers of action in any part of the body, would we, for the pur-
pose, apply to that part intense heat or cold, mechanical violence or strong
chemical irritants? It is scarcely necessary to reply that we would not. The
agents we would employ would be of a different description. It may be laid
down as a physical axiom, that whatever gives severe pain tends to dimi-
nish power in the part affected. It exhausts the vital energy, which is itself
the source of both action and power.

Had we leisure to examine analytically the nature and operation of the
remedies best adapted to the cure of topical inflammation, we should find
them to be such as are calculated to increase, not to diminish, the action of
the vessels. With the exception of blood-letting local and general, they are
all of a stimulating character. Cold and heat, blistering and spirits of tur-
pentine, are included in the number. In this case, even blood-letting itself
would seem to operate as an indirect stimulant. Besides relieving the vessels
of the inflamed part from the irritation of a portion of superabundant bldod,

206 PRACTICE OF PHYSIC.

increased impetus of the blood in the particular part is
owing especially to the increased action of the vessels
of that part itself.

240. The cause of this increased action in the ves-

it leaves them at liberty to contract by taking off that fulness and tension,
which, by inducing in them a paralysis, prevents their action

Were we ourselves to attempt to lay down a theory of inflammation, it
would be somewhat as follows :

We would, as a preliminary, observe, what every physiologist already
knows, that the circulation of the blood through the capillary vessels, in-
stead of depending on the impetus communicated to it by the heart, is
effected, if not entirely, at least in a great measure, by the action of the ves-
sels themselves. Hence a paralysis, <<r want of power in an\ portion of them,
produces, of necessity, in that portion, a stagnation of the blood

By the operation of some irritating agent, the presence of v bich we cannot
always discover, this paralysis or want of the power of action takes place in
the capillaries of a certain organ or part. The consequence is, a stagnation
of the blood in that part, because there is nothing to keep it in motion. But
the evil does not terminate here. The action of the heart and larger arte-
ries continuing, and being even augmented by means of the existing irrita-
tion, what was at first a mere stagnation in the capillaves, becomes an accu-
mulation, in consequence of the blood that is constantly thrown into them.
This blood is perceived to be arterial Hence the redntss, tension, pain and
swelling, which constitute the leading phenomena of inflammation. To re-
move these phenomena, provided the disease be local, nothing is neces-
sary but the excitement of action in the affecn-d vessels, by mean.-, of which
the blood may be forced along in its usual channels. If the disease be gene-
ral, and the vis a tergo increased, blood-letting is requisite.

In case the inflammation be phlegmonous, and the natural action of the
vessels cannot be restored, in time to prevent their own rupture or the death
and mortification of the part, they assume, by the powers of nature, a new
action, in order to free themselves from their superabundant contents They
put on a glandular character, and secrete pus. In this way they discharge
by secretion the blood which, had they been capable of action, would have
passed through them by ordinary circulation.

From the foregoing representations it appears, that, to produce local in-
flammation, nothing is necessary but an irritation connected with a want of
the power of action in a portion of the capillary vessels, the force of the
circulation throughout the system remaining unaltered. To render this in-
flammation general, the impetus of the circulation, and consequently the
force, of the vis a tergo, in relation to the topical affection, must be increased.

Dr. Cullen, convinced himself that a remora or obstruction to the free and
rapid passage of the blood through the vessels of an inflamed part does
take place, has attributed this phenomena to the influence of spasm. In his
view, therefore, of the mere mechanism of inflammation, he appears to have
been right ; in that of its proximate cause, we think he was wrong.

PRACTICE OF PHYSIC. 207

sels of a particular part is, therefore, what we are to con-
sider as the proximate cause of inflammation.

In many cases, we can manifestly perceive, that in-
flammation arises from the application of such stimu-
lant substances to the part. When the application of
such stimulants, therefore, is evident, we seek for no
other cause of inflammation: but as, in many cases,
such application is neither evident, nor, with any pro-
bability, to be supposed, we must, in such cases, seek
for some other cause of the increased impetus of the
blood in the vessels of the part.

241. Many physicians have supposed, that an ob-
struction of the extreme vessels, any how produced,
may prove a cause of inflammation; and particularly,
that this may arise from an obstruction formed by a mat-
ter stopping up these vessels. But many difficulties at-
tend this doctrine.

1. The opinion seems chiefly to have arisen from the
appearance of the blood described in (237.) when the
separated gluten was considered as a preternatural and
morbid matter; but we now know very certainly, that
this gluten is constantly a constituent part of the human
blood; and that it is only a peculiar separation of the
parts of the blood that happens in consequence of in-
flammation and some other circumstances, which gives
occasion to the appearance that was falsely considered
as a mark of a morbid lentor in the blood.

2. There are no experiments directly in proof of a
preternatural lentor prevailing in the mass of blood; nor
is there any evidence of certain parts of the blood oc-
casionally acquiring a greater density and force of co-
hesion than ordinary; neither is there any proof of the
denser or more coherent parts being present in the mass
of blood, in such greater proportion than usual, as to
occasion a dangerous spissitude. The experiments of

208 PRACTICE OF PHYSIC.

Dr. Brown Langrish on this subject afford no conclu-
sion, having been made on certain parts of the blood
separated from the rest, without attending to the cir-
cumstances of blood-letting, which very much alter the
state of the separation and concretion of the blood
drawn out of the veins.

3. The supposition of a preternatural lentor or vis-
cidity of the blood, is not well founded; for it is proba-
ble, that nature has specially provided against a state of
the fluids, so incompatible with the exercise of the most
important functions of the animal economy. While mo-
tion continues to prevent any separation of parts, and
heat continues to preserve the fluidity of the more vis-
cid, there seems to be always so large a proportion of
water present as to give a sufficient fluidity to the
whole. I must own that this is not absolutely conclu-
sive; but I still repeat it, as giving a probability to the
general argument.

4. In the particular case of inflammation, there are
several circumstances which render it probable that the
blood is then more fluid than usual.

5. I presume that no such general lentor, as Boer-
haave and his disciples have supposed, does ever take
place; because if it did, it must show more considera-
ble effects than commonly appear.

6. Besides the supposition of an obstructing lentor,
physicians have supposed, that an obstruction may be
formed by an impermeable matter of another kind, and
that such an obstruction may also be the cause of in-
flammation. This supposition is what is well known in
the schools under the title of an error loci; but it is an
opinion that I cannot find to be at all probable; for the
motion of the blood in the extreme vessels is so weak
and slow, as readily to admit a retrograde course of it;
and therefore, if a particle of blood should happen to

PRACTICE OF PHYSIC. 209

enter a vessel whose branches will not allow of its pas-
sage, it will be moved backwards, till it meet with a ves-
sel fit for transmitting it; and the frequent ramifications
and anastomoses of the extreme arteries are very fa-
vourable to this. I must own, indeed, that this argu-
ment is not absolutely conclusive; because I allow it to
be pretty certain, that error loci does actually upon oc-
casion happen; but for the reasons I have given, it is
probable that it seldom happens, and is therefore rarely
the cause of inflammation: or if it be, that it is not
merely by the obstruction that it produces; as, among
other reasons, I conclude particularly from the follow-
ing argument.

7. Though an obstruction should be supposed to take
place, it will not be sufficient for producing the effects,
and exhibiting the phenomena, that appear in inflam-
mation. The theory that has been commonly employed
on this occasion is by no means satisfying; and, in fact,
it appears, from many observations and experiments,
that considerable obstructions may be formed, and may
subsist, without producing the symptoms of inflamma-
tion.

242. Obstruction, therefore, from a matter stopping
up the vessels, {Gaub. Pathol. 249. i.) is not to be con-
sidered as the primary cause of inflammation; but at
the same time, it is sufficiently probable, that some de-
gree of obstruction does take place in every case of in-
flammation. The distention, pain, redness and tumour,
attending inflammation, are to be explained only by sup-
posing, that the extremities of the arteries do not readily
transmit the unusual quantity of blood impelled into
them by the increased action in the course of these ves-
sels. Such an obstruction may be supposed to happen
in every case of an increased impetus of the bloo but
it is probable, that in the ca-e of inflammation, theie is

VOL. i. d d

210 PRACTICE OF PHYSIC.

also a preternatural resistance to the free passage of the
fluids.

243. From the doctrine of fever, we are led to be-
lieve, that an increased action of the heart and arteries
is not supported for any length of time, by any other
means than a spasm affecting the extreme vessels; and
that the same spasm takes place in inflammation seems
likely, because that every considerable inflammation is
introduced by a cold stage, and is accompanied with
that and other, circumstances of pyrexia. It seems also
probable, that something analogous to this occurs even
in the Case of those inflammations which appear less
considerable, and to be purely topical.

244. From all this the nature of inflammation may
in many cases be explained in the following' manner.
Some causes of inequality in the distribution of the blood
may throw an unusual quantity of it upon particular
vessels, to which it must necessarily prove a stimulus.
But, further, it is probable, that to relieve the conges-
tion, the vis medicatrix nalurce increases still more the
action of these vessels; and which, as in all other febrile
diseases, it affects by the formation of a spasm on their
extremities.

245. A spasm of the extreme arteries, supporting an
increased action in the course of them, may therefore
be considered as the proximate cause of inflammation;
at least, in all cases not arising from direct stimuli ap-
plied; and even in this case the stimuli may be supposed
to produce a spasm of the extreme vessels.

24G. That, in inflammation, th< re is the concurrence
of a constriction of the extreme vessels, with an in-
creased action in the other parts of them, seems pro-
bable, from the consideration of Rheumatism. This is
a species of inflammation which is often manifestly pro-
duced, either by cold applied to over-distended vessels,

PRACTICE OF PHYSIC. 211

or by causes of an increased impetus, and over-disten-
tion in vessels previously constricted. Hence the dis-
ease especially appears at seasons liable to frequent and
considerable vicissitudes of heat and cold.

To this we may add, that the parts of the body most
frequently affected with inflammation, are those expos-
ed, both to over-distention, from a change in the distri-
bution of the fluids, and, at the same time, to the imme-
diate action of cold. Hence, quinsies, and pneumonic
inflammations, are more frequent than any others.

247. That a spasm of the extreme vessels takes place
in inflammation, is to be further presumed from what is
at the same time the state of the whole arterial system.
In every considerable inflammation, though arising in
one part only, an affection is communicated to the whole
system, in consequence of which an inflammation is
readily produced in other parts beside that first affected.
This general affection is well known among physicians,
under the name of the diathesis phlogistica. It
appears most commonly in persons of the most rigid fi-
bres: is often manifestly induced by the tonic or astrin-
gent powers of cold; is increased by all tonic and stimu-
lant powers applied to the body; is always attended with
a hardness of the pulse; and is most effectually taken
off by the relaxing power of blood-letting. From these
circumstances, it seems probable, that the diathesis phlo-
gistica consists in an increased tone, or contractility,
and perhaps in an increased contraction of the muscu-
lar fibres of the whole arterial system. Such a state of
the system seems often to arise, and subsist for some
time, without the apparent inflammation of any particu-
lar part; but such a state of the system renders it likely,
that a spasm may at the same time readily arise in any
of the extreme vessels, and a particular inflammation be
there produced. It does, however, appear, also,, that

212 PRACTICE OF PHYSIC.

the general diathesis frequently arises from inflamma-
tion begun in a particular part.

248. I have thus endeavoured, in the case of inflam-
mation, to explain the state of the whole system, as well
as that of the part more particularly affected. The lat-
ter I have considered as when in its first formation; but
aft' r it has subsisted for some time, various changes
take place in the part affected; and of these I must now
take notice.

Sect. III. — Of the Terminations of Inflammation.

249. If an inflammation be cured while the state and
texture of the part remain entire, the disease is said to
be terminated by resolution.

This happens when the previous congestion and
spasm have been in a moderate degree, and the increased
impetus of the blood has been sufficient to overcome
the spasm, to dilate the vessels and to remove the con-
gestion so that the part is restored to its ordinary and
healthy state.

A resolution takes place also when the increased im-
petus of the fluids has produced an increased exhala-
tion into the adjoining cellular texture, or an increased
excretion in some neighbouring part, and has thereby
relaxed the spasm, and relieved the congestion, in the
vessels of the part more particularly affected.

Lastly, a resolution may take place, when the increas-
ed impetus of the blood in the whole system occasions
an evacuation, which, though in a distant part, may
prove sufficient to take off the phlogistic diathesis of the
whole system, and thereby relieve the congestion and
spasm of the particular part affected by inflammation.

250. The tumour which appears in inflammation may
be imputed in part to the congestion of fluids in their

PRACTICE OF PHYSIC. 213

proper vessels ; but is owing chiefly to an effusion of
matter into the adjoining cellular texture; and, accord-
ingly, tumours seldom appear but in parts adjoining to
a lax cellular texture. If in this case, the matter effused
be only a larger quantity of the ordinary exhaling fluid,
this, when the free circulation in the vessels is restored,
will be readily absorbed, and the state of the part will
become the same as before. But if the increased im-
petus of the blood in an inflamed part, dilate the exha-
lant vessels to such a degree, that they pour out an entire
serum, this will not be so readily reabsorbed; and, from
the experiments of Sir John Pringle, and especially
from those of Mr. Gaber, Miscell. Taurin. Vol. II., we
learn, that the serum, under stagnation, may suffer a
particular change, by having the gluten present in it
changed into a white, opaque, moderately viscid, mild
liquor, which we name pus. When this change takes
place in the inflamed part, as it is at the same time at-
tended with an abatement of the redness, heat, and
pain, which before distinguished the inflammation, so
the disease is said to be terminated by suppuration;
and an inflamed part, containing a collection of pus, is
called an abscess.*

251. In inflammation, the tendency of it to suppura-
tion may be discovered by the long continuance of the

* Pus is not produced by a mere change in an effused and stagnant por-
tion of fluid. It is now known to be the result of morbid glandular action.
It is as genuine a secretion from the blood as bile or urine, saliva or the pan-
creatic juice. As already intimated, it is formed by the glandular action of
the capillaries, which nature, in her wisdom and resources, enables them to
assume, in order that they may relieve themselves from the superabundance
of blood which oppresses them.

For a correct theory of the formation of pus, we are indebted to an Ameri-
can physician — the late Dr. Morgan of Philadelphia. For the Doctor's views
on this subject, see his excellent Inaugural Dissertation published in Edin-
burgh, in the Latin tongue, in the year 1765. For the honour of American
medical literature, this essay ought to be republished, and every physician
of our country should qualify himself to read it in the language in which it
appears.

214 PRACTICE OF PHYSIC.

inflammation, without the symptoms of resolution; by
some remission of the pain of distention; by the pain
becoming of a throbbing kind, more distinctly connect-
ed with the pulsation of the arteries being fuller and
softer; and often by the patient's being frequently af-
fected with cold shiverings. The period at which this
takes place is not determined, but may be sometimes
sooner, sometimes later. When the tendency is deter-
mined, the time necessary to a complete suppuration is
different in different cases.

When pus is completely formed, the pain in the part
entirely ceases, and a weight is felt in it. If the collec-
tion be formed immediately under the skin, the tumour
becomes pointed, the part becomes soft, and the fluctu-
ation of the fluid within can commonly be perceived;
while at the same time, for the most part, the redness
of the skin formerly prevailing is very much gone.

252. In abscesses, while the pus is formed of one part
of the matter which had been effused, the other and
thinner parts are reabsorbed, so that in the abscess,
when opened, a pus alone appears. This pus, how-
ever, is not the converted gluten alone; for the conver-
sion of this being the effects of a particular fermenta-
tion, which may affect the solid substance of the part,
and perhaps every solid of animal bodies; so it most
readily, and particularly, affects the cellular texture,
eroding much of it, which therein, becomes a part of
the pus. It generally happens also, that some of the
smaller red vessels are eroded, and thereby some red
blood often appears mixed with the pus in abscesses.
Upon the whole, the internal surface of an abscess is to
be considered as an ulcerated part.*

* In cases of suppuration there occurs no erosion of the solid parts by
means of either a fermentation, or the action of an acrimonious fluid pro-

PRACTICE OF PHYSIC. 215

253. This account of suppuration explains, why an
abscess, when formed, may either spread into the cellu-
lar texture of the neighbouring parts; or by eroding the
incumbent teguments, be poured out upon the surface
of the body, and produce an open ulcer.

25 4. We have here given the idea of abscess as a
collection of matter following inflammation; but the term
has been applied to every collection of matter effused,
and changed by stagnation in an enclosed cavity.

The matter of abscesses, and of the ulcers following
them, is various, according to the nature of what is
effused, and which may be,

1. A matter thinner than serum.

2. An entire and pure serum.

3. A quantit) of red globules.

4. A matter furnished by particular glands seated in
the part.

5. A mixture of matters from different sources,
changed by peculiar fermentation.

It is the second only which affords a proper pus; the
effusion whereof, whether in suppurating parts or ulcers,
seems to be the peculiar effect of an inflammatory state
of the vessels; and for this reason it is, that, when ulcers
do not produce a proper pus, a circumstance always
absolutely necessary to their healing, we, in many cases,
bring the ulcers to a state of proper suppuration, by
the application of stimulants exciting inflammation, such
as balsams, mercury, copper, &c.

255. When the matter effused into the cellular tex-
ture of an inflamed part is tainted with a putrid fer-

dticed. The removal of the solid matter which takes place in ulceration is
to be attributed entirely to the action of the absorbents.

We might here remark, that there does not exist a more plain and striking
manifestation of 'he sanative powers of nature, than that of internal ulcera-
tion always travelling towards the surface of the body, so as to discharge the
contents of abscesses through the skin.

216 PRACTICE OF PHYSIC.

merit, this produces in the effused matter a state ap-
proaching more or less to that of putrefaction. When
this is in a moderate degree, and affects only the fluids
effused, with the substance of the cellular texture, the
part is said to be affected with gangrene; but if the
putrefaction affect also the vessels and muscles of the
part, the disease is said to be a sphacelus.

256. A gangrene, and its consequences, may arise
from a putrid ferment diffused in the mass of blood, and
poured out with the serum effused ; which it operates
upon more powerfully while the serum is stagnant, and
retained in the heat of the body: bnt it may also arise
from the peculiar nature of the matter effused being
disposed to putrefaction ; as particularly seems to be the
case of the red globules of the blood effused in a large
quantity. In a third manner also, a gangrene seems
frequently to arise from the violent excitement of the
inflammation destroying the tone of the vessels; where-
by the whole fluids stagnate and run into putrefaction,
which taking place in any degree, destroys still further
the tone of the vessels, and spreads the gangrene.*

257. In inflammation, the tendency to gangrene may
be apprehended from an extreme violence of pain and
heat in the inflamed part, and from a great degree of
pyrexia attending the inflammation.

The actual coming on of gangrene may be perceived
by the colour of the inflamed part changing from a clear
to a dark red; by blisters arising upon the part; by the
part becoming soft, flaccid, and insensible; and by the
ceasing of all pain while these appearances take place.

As the gangrene proceeds, the colour of the part be-
comes livid, and by degrees quite black; the heat of the

* It is to a -want of sufficient vitality in the solids, and not to any " putrid
ferment" in the blood, that we are to look as the source of gangrene and
sphacelus. We repeat, for the last time in our annotations, that no putrid
ferment ever exists in the blood.

PRACTICE OF PHYSIC. 2\1

part entirely ceases; the softness and flaccidity of the
part increase; it loses its consistence, exhales a cadave-
rous smell, and may be then considered as affected with
sphacelus.

258. Gangrene is thus a third manner in which in-
flammation terminates; and the schools have commonly
marked a fourth termination of inflammation; which is,
by a scirrhus, or an indolent hardness of the part for-
merly affected with inflammation. This, however, is a
rare occurrence, and does not seem to depend so much
upon the nature of inflammation, as upon the circum-
stances of the part affected. It is in glandular parts
chiefly that scirrhosity is observed; and it is probably
owing to the parts readily admitting a stagnation of the
fluids. [ have observed, that inflammation seldom in-
duces scirrhus; but that this more commonly arises
from other causes; and when inflammation supervenes,
which it is sooner or later apt to do, it does not so com-
monly increase, as change the scirrhosity into some
kind of abscess. From these considerations it does not
seem necessary to take any further notice of scirrhus
as a termination of inflammation.

259. There are, however, some other terminations of
inflammation, not commonly taken notice of, but now
to be mentioned.

One is, by the effusion of a portion of the entire
mass of blood, either by means of rupture or of anas-
tomosis, into the adjoining cellular texture. This hap-
pens especially in inflammations of the lungs, where the
effused matter, by compressing the vessels, and stopping
the circulation, occasions a fatal suffocation: and this is
perhaps the manner in which pneumonic inflammation
most commonly proves fatal.

260. Another kind of termination is, that of certain
inflammations on the surface of the body, when there

vol. i. e e

218 PRACTICE OF PHYSIC.

is poured out under the cuticle a fluid, which being too
gross to pass through its pores, therefore separates it
from the skin, and raises it up into the form of a vesicle
containing the effused fluid; and by which effusion the
previous inflammation is taken off.

261. Besides these already mentioned, I believe there
is still another manner in which inflammation terminates.
When the internal parts are affected with inflammation,
there seems to have been almost always upon their sur-
face an exudation, which appears partly as a viscid con-
cretion upon their surface, and partly as a thin serous
fluid effused into the cavities in which the inflamed vis-
cera are placed. Though we have become acquainted
with these appearances only, as very constantly accom-
panying those inflammations which have proved fatal, it
is, however, probable, that like circumstances may have
attended those which have terminated by resolution, and
may have contributed to that event. It is in favour of
this supposition that there are instances of pneumonic
inflammation terminating in a hydrothorax.*

Sect. IV. — Of the Remote Causes of Inflammation.

262. The remote causes of inflammation may be re-
duced to five heads.

1. The application of stimulant substances, among
which are to be reckoned the action of fire, or burn-
ing.

2. External violence operating mechanically in
wounding, bruising, compressing, or overstretching the
parts.

* Real Dropsy may be safely represented as one of the modes in which
inflammation occasionally terminates. I'erhaps hydrothorax seldom arises
from any other source- To the same cause may we attribute ascites, in
every instance, where the fluid effused is gelatinous and viscid; and in
many where it is perfectly serous, the character of the disease is evidently
inflammatory. Hydrocele is also the result of inflammation.

PRACTICE OF PHYSIC. 219

3. Extraneous substances, lodged in any part of the
body, irritating by their chemical acrimony or mecha-
nical form, or compressing by their bulk or gravity.

4. Cold, in a certain degree, not sufficient immedi-
ately to procure gangrene.

5. An increased impetus of the blood determined to
a particular part.

It will not be difficult to understand how these re-
mote causes, singly, or in concurrence, produce the
proximate cause of inflammation.*

263. It does not appear, that in different cases of in-
flammation, there is any difference in the state of the
proximate cause, except in the degree of it; and though
some difference of inflammation may arise from the
difference of the remote causes, yet this is not neces-
sary to be taken notice of here; because the different
appearances which attend different inflammations may
be referred, for the most part, to the difference of the
part affected, as will appear when we shall consider
the several genera and species marked in the Nosology.
When I come to treat of these, I shall find a more pro-
per occasion for taking notice of the different states of
the proximate, or of the differences of the remote cause,
than by treating of them in general here.f

* Our author had better, perhaps, have said, in general terms, that inflam-
mation is produced by the operation of certain irritants — it being impossible
for it to arise from any other source — and then proceeded to enumerate and
classify these irritants, according to their affinities. In his present arrange-
ment there is confusion and tautology, certain articles included under his
second and third heads being substantially the same.

In his exposition of his fifth head he is lame and defective. If there exist
"an increased impetus of the blood determined to a particular part," it must
be necessarily as the result of some irritating agent. To allege the contrary,
would be to admit the existence of an effect without a cause.

j- Inflammations differ materially in their character according to the causes
that produce them. Those arising from the action of fire and frost, while
they are unlike all others, are also marked by a very striking difference be-
tween themselves. Burns and chilblains may be regarded in the light of

22Q PRACTICE OF PHYSIC.

Sect. V. — Of the Cure of Inflammation.

264. The indications of cure in inflammation are
different, according as it still may be capable of resolu-
tion, or may have taken a tendency to the several other
terminations above mentioned. As the tendency to
these terminations is not always immediately evident, it
is always proper, upon the first appearance of inflam-
mation, to attempt the cure of it by resolution. For
this purpose, the indications of cure are,

1. To remove the remote causes, when they are evi-
dent, and continue to operate.

2. To take off the phlogistic diathesis affecting either
the whole system, or the particular part.

3. To take off the spasm of the particular part, by
remedies applied either to the whole system, or to the
part itself.

265. The means of removing the remote causes will
readily occur, from considering the particular nature and
circumstances of the different kinds. Acrid matters must
be removed, or their action must be prevented, by the
application of correctors and demulcents. Compressing
and overstretching powers must be taken away; and,
from their several circumstances, the means of doing so
will be obvious.*

266. The means of taking off the phlogistic diathe-
sis of the system, are the same with those for moderat-
ing the violence of reaction in fever, which are men-
specific affections. They put on appearances and require modes of treat-
ment different from those of other inflammations. They produce, also, in
those affected by them, different sensations.

* If the irritating cause be of an alkaline nature, neutralize it by an acid ;
and if of an acid character, neutralize it by an alkali. But if it be neither
acid nor alkaline, diluents and demulcents may be employed with the pros-
pect of advantage.

PRACTICE OF PHYSIC. 221

tion^d and treated of (from 127. to 149.) and therefore
need not be repeated here. I only observe, that in the
use of those remedies, there is less occasion for any re-
serve than in many cases of fever; and more particu-
larly, that topiral bleedings are here particularly indi-
cated and proper.

267. The means of taking off the spasm of the par-
ticular part are nearly the same as those mentioned
above, for taking off the spasm of the extreme vessels
in the case of fever, and which are treated of (from 1 50
to 200.) Only it is observed here, that some of these
are here especially indicated, and that some of them are
to be directed more particularly to the part especially
affected, the. management of which will be more pro-
perly considered, when we shall treat of particular in-
flammations.

26S. When a tendency to suppuration (251.) is dis-
tinctly perceived, as we suppose it to depend upon the
effusion of a fluid which cannot be easily reabsorbed, so
it becomes necessary that this fluid be converted into
pus, as the only natural means of obtaining its evacua-
tion; and as the effusion is, perhaps, seldom made with-
out some rupture of the vessels, to the healing of which
a pus is absolutely necessary; so, in the case of a ten-
dency to suppuration, the indication of cure always is,
to promote the production of a perfect pus as quickly
as possible.

269. For this purpose, various remedies, supposed to
possess a specific power, have been proposed; but I can
perceive no such power in any of them ; and in my opi-
nion, all that can be done is, to favour the suppuration
by such applications as may support a proper heat in
the part, as by some tenacity may confine the perspira-
tion of the part, and as, by an emollient quality, may

222 PRACTICE OF PHYSIC.

weaken the cohesion of the teguments, and favour their
erosion.*

210. As, in the case of certain effusions, a suppura-
tion is not only unavoidable, but desirable, it may be sup-
posed, that most of the means of resolution formerly
mentioned should be avoided; and accordingly our prac-
tice is commonly so directed. But, as we observe, on
the one hand, that a certain degree of increased impe-
tus, or of the original circumstances of inflammation, is
requisite to produce a proper suppuration; so it is then
especially necessary to avoid those means of resolution
that may diminish too much the force of the circulation.
And as, on the other hand, the impetus of the blood,
when violent, is found to prevent the proper suppuration;
so, in such cases, although a tendency to suppuration
may have begun, it may be proper to continue those
means of resolution which moderate the force of the
circulation.

With respect to the opening of abscesses, when com-
pletely formed, I refer to the writings on surgery.

271. When an inflammation has taken a tendency to
gangrene, that event is to be prevented by every possible
means; and these must be different, according to the na-
ture of the several causes occasioning that tendency, as
may be understood from what has been already said of
them. After a gangrene has, in some degree, taken
place, it can be cured only by the separation of the dead

* The mode of practice best calculated to promote suppuration, is the ap-
plication and frequent renewal of large, soft, and warm poultices, composed
of materials retentive of heal. Oily and mucilaginous substances should
enter largely into the composition of these articles. No better poultice,
perhaps, can be formed, than that which consists of proper proportions of
light bread and milk, flaxseed, and olive oil or fresh lard. The diet and re-
gimen must be suited to the state and habits of body of the diseased — ge-
nerous and free, if great debility prevail; and the reverse, in cases of gene-
ral inflammatory action.

PRACTICE OF PHYSIC. 223

from the living parts. This, in certain circumstances,
can be performed by the knife, and always most pro-
perly, when it can be so done.

In other cases, it can be done by exciting a suppura-
lory inflammation on the verge of the living part, whereby
its cohesion with the dead may be every where broken
off, so that the latter may fall off by itself. While this
is doing, it is proper to prevent the further putrefaction
of the part, and its spreading wider. For this purpose,
various antiseptic applications have been proposed: but
it appears to me, that while the teguments are entire,
these applications con hardly have any effect; and, there-
fore, that the fundamental procedure must be to scarify
the part so as to reach tlje living substance, and by the
wounds made there, to excite the suppuration required.
By the same incisions also, we give access to antisep-
tics, which may both prevent the progress of the putre-
faction in the dead, and excite the inflammation neces-
sary on the xer^e of the living part.*

212. When the gangrene proceeds from a loss of tone;
and when this, communicated to the neighbouring parts,
prevents that inflammation which, as I have said, is ne-
cessary to the separation of the dead part from the liv-
ing; it will be proper to obviate this loss of tone by tonic
medicines given internally; and, for this purpose, the
Peruvian bark has been found to be especially effectual.
That this medicine operates by a tonic power, I have
endeavoured to prove above, (214.) and from what is
said in 215. the limitations to be observed in employing
it may also be learned. When the gangrene arises from
the violence of inflammation, the bark may not only

* The separation between the dead and living parts, in cases of gangrene,
is effected by ulcerative inflammation — in other words, it results from the ac-
tion of the absorbents. Solid living matter is never melted down nor wasted
away, either by a putrid, or any other kind of ferment.

2?4 PRACTICE OF PHYSIC.

fail of proving a remedy, but may do harm: and its
power as a tonic is especially suited to those cases of
gangrene which proceed from an original loss of tone,
as in the case of palsy and oedema; or to those cases
of inflammation where a loss of tone takes place, while
the original inflammatory symptoms are removed.

273. The other terminations of inflammation either
do not admit of any treatment, except that of preventing
them by the means of resolution ; or they belong to a trea-
tise of surgery rather than to this place.

Having thus, therefore, delivered the general doc-
trine, I proceed now to consider the particular genera
and species of inflammation.

It has been hinted above (263.) that the difference
of inflammation arises chiefly from the difference of the
part affected: I have therefore arranged them as they
are cutaneous, visceral, or articular; and in this
order they are now to be considered.

CHAPTER II.
OF INFLAMMATION, MORE STRICTLY CUTANEOUS.

274, CUTANEOUS inflammations are of two kinds,
commonly distinguished by the names of phlegmon
and erysipelas.

Of the latter there are two cases, which ought to be
distinguished by different appellations. When the disease
is an affection of the skin alone, and very little of the
whole system, or when the affection of the system is
only symptomatical of the external inflammation, I shall
give the disease the name of erythema: but when the
external inflammation is an exanthema, and symptoma-

PRACTICE OF PHYSIC. 225

tical of an affection of the whole system, I shall then
name the disease erysipelas.

275. It is the erythema only that I am to consider here.

For the distinction between Erythema and Phlegmon,
I have formerly referred to the characters given of them
in our Nosology. See Synops. Nosolog. Aieth. vol. ii.
p. 5. gen. vii. spec. 1. and 2. But I think it proper
now to deliver the characters of them more fully and
exactly here, as follows.

A Phlegmon is an inflammatory affection of the skin,
with a swelling, rising generally to a more considerable
eminence in the middle of it; of a bright red colour ;
both the swelling and celour being pretty exactly cir-
cumscribed; the whole being attended with a pain of
distention, often of a stounding or throbbing kind, and
frequently ending in suppuration.

An Erythema, Rose, or St. Anthony's Fire, is an in-
flammatory affection of the skin, with hardly any evi-
dent swelling; of a mixed, and not very bright red co-
lour, readily disappearing upon pressure, but quickly
returning again; the redness of no regular circumscrip-
tion, but spreading unequally, and continuing almost
constantly to spread upon the neighbouring part; with
a pain like to that from burning; producing blisters,
sometimes of a small, sometimes of a larger size ; and
always ending in a desquamation of the scarf-skin,
sometimes in gangrene.

This subject I am not to prosecute here, as properly
belonging to surgery, the business of which I am seldom
to enter upon in this work; and shall therefore observe
only as necessary here, that the difference of these ap-
pearances seems to depend upon the different seat of the
inflammation. In the phlegmon the inflammation seems
to affect especially the vessels on the internal surface of
the skin communicating with the lax subjacent cellular

vol. t. f f

,22ti PRACTICE OF PHYSIC.

texture; whence a more copious effusion, and that of
serum convertible into pus, takes place. In the ery-
thema, the inflammation seems to have its seat in the
vessels on the external surface of the skin, communi-
cating with the rete mucosum, which does not admit
of any effusion, but what separates the cuticle, and gives
occasion to the formation of a blister, while the smaller
size of the vessels admits only the effusion of a thin
fluid, very seldom convertible into pus.

Besides these differences in the circumstances of these
two kinds of inflammation, it is probable that they also
differ with respect to their causes. Erythema is the effect
of all kinds of acrids externally applied to the skin; and,
when arising from an internal cause, it is from an acri-
mony, poured out on the surface of the skin under the
cuticle. In the phlegmon, an acrimony is not commonly
evident*

276. These differences in the seat and causes of the
phlegmon and erythema being admitted, it will be evident
that, when an erythema affects any internal part, it can
take place in those only whose surfaces are covered with
an epithelion, or membrane analogous to the cuticle.

277. The same distinction between the seat and
causes of the two diseases will, as I judge, readily explain
what has been delivered by practical writers with respect
to the cure of these different cutaneous inflammations.
But I shall not, however, prosecute this here, for the
reason given above, (275.) and, for the same reason,
shall not say any thing of the variety of external inflam-
mation that might otherwise be considered here.

* The difference between Phlegmon and Erythema we believe to be, that
the former originates in the skin, or cellular membrane, and is literally,
therefore, a cutaneous disease ; while the latter has its origin in the stomach,
and affects the skin secondarily by sympathy. Hence, erythema is neces-
sarily the more serious disease. In Erythema the best topical application is
a blister. Spirits of turpentine are said to be useful ; but we have never
seen thenj applied.

PRACTICE OF PHYSIC. 221

CHAPTER lit.
OF OPHTHALMIA, OR INFLAMMATION OF THE EYE.

278. THE inflammation of the eye may be considered
as of two kinds; according as it has its seat in the mem-
branes of the ball of the eye, when I would name it
ophthalmia membranarum; or as it has its seat in the
sebaceous glands placed in the tarsus, or edges of the
eyelids, in which case it may be termed ophthalmia
tarsi.

These two kinds are very frequently combined toge-
ther, as the one may readily excite the other; but they
are still to be distinguished according as the one or the
other may happen to be the primary aifection, and pro-
perly as they often arise from different causes.

279. The inflammation of the membranes of the eye
affects especially, and most frequently, the adnata, ap-
pearing in a turgescence of its vessels; so that the red
vessels which are naturally there, become not only in-
creased in size, but there appear many more than did
in a natural state. This turgescence of the vessels is
attended with pain, especially upon the motion of the
ball of the eye; and this, like every other irritation
applied to the surface of the eye, produces an effusion
of tears from the lachrymal gland.

This inflammation commonly, and chiefly, affects the
adnata spread on the anterior part of the bulb of the eye;
but usually spreads also along the continuation of that
membrane on the inside of the palpebrae; and, as that is
extended on the tarsus palpebrarum, the excretories of
the sebaceous glands opening there are also frequently

22S PRACTICE OF PHYSIC.

affected. When the affection of the adnata is consider-
able, it is frequently communicated to the subjacent
membranes of the eye, and even to the retina itself,
which thereby acquires so great a sensibility, that the
slightest impression of light becomes painful.

280. The inflammation of the membranes of the eye
is in different degrees, according as the adnata is more
or less affected, or according as the inflammation is
either of the adnata alone, or of the subjacent mem-
branes also; and upon these differences, different spe-
cies have been established, and different appellations
given to them. But I shall not, however, prosecute
the consideration of these, being of opinion, that all the
cases of the Ophthalmia membranarum differ only in
degree, and are to be cured by remedies of the same
kind, more or less employed.

The remote causes of Ophthalmia are many and va-
rious; as,

1. External violence, by blows, contusions, and
wounds, applied to the eyes; and even very slight im-
pulses applied, while the eyelids are open, to the ball
of the eye itself, are sometimes sufficient for the pur-
pose.

2. Extraneous bodies introduced under the eyelids,
either of an acrid quality, as smoke and other acrid va-
pours, or of a bulk sufficient to impede the free motion
of the eyelids upon the surface of the eyeball.

3. The application of strong light, or even of a mo-
derate light long continued.

4. The application of much heat, and particularly of
that with moisture.

5. Much exercise of the eyes in viewing minute ob-
jects.

6. Frequent intoxication.

PRACTICE OF PHYSIC. 229

7. Irritation from other and various diseases of the
eyes.

8. An acrimony prevailing in the mass of blood, and
deposited in the sebaceous glands on the edges of the
eyelids.

9. A change in the distribution of the blood, whereby
either a more than usual quantity of blood, and with
more than usual force, is impelled into the vessels of the
head, or whereby the free return of the venous blood
from the vessels of the head is interrupted.

10. A certain consent of the eyes with the other
parts of the system, whereby from a certain state d"
these parts, either a simultaneous or an alternating af-
fection of the eyes is produced.

281. The proximate cause of Ophthalmia, is not dif-
ferent from that of inflammation in general; and the dif-
ferent circumstances of Ophthalmia may be explained
by the difference of its remote causes, and by the dif-
ferent parts of the eye which it happens to affect. This
may be understood from what has been already said;
and I shall now, therefore, proceed to consider the

CURE.

282. In the cure of Ophthalmia, the first attention
will be always due to the removing of the remote causes,
and the various means necessary for this purpose will
be directed by the consideration of these causes enu-
merated above.

The Ophthalmia membranarum requires the reme-
dies proper for inflammation in general; and when the
deeper seated membranes are affected, and especially
when a pyrexia is present, large general bleedings may
be necessary. But this is seldom the case, as the Oph-
thalmia, for the most part, is an affection purely local,
accompanied with little or no pyrexia. General bleed-
ings, therefore, from the arm or foot, have little effect

230 PRACTICE OF PHYSIC.

upon it; and the cure is chiefly to be obtained by topi-
cal bleedings, that is, blood drawn from the vessels near
the inflamed part; and opening the jugular vein or the
temporal artery, may be considered as in some measure
of this kind. Ft is commonly sufficient to apply a num-
ber of leeches around the eye; and it is perhaps better
still to draw blood from the temples by cupping and
scarifying. In many cases, a very effectual remedy is,
that of scarifying the internal surface of the inferior
eyelid ; and more so still, is cutting the turgid vessels
upon the adnata itself.*

283. Besides blood-letting, purging, as a remedy
suited to inflammation in general, has been considered
as peculiarly adapted to inflammations in any of the
parts of the head, and therefore to Ophthalmia; and it
is sometimes useful; but, for the reasons given before
with respect to general bleeding, purging in the case of
Ophthalmia does not prove useful in any degree in
proportion to the evacuation excited.

284. For relaxing the spasm in the part, and taking

* In one sentiment which our author advances in this paragraph we can-
not altogether concur. We have seen several, we think many, cases of
Opthalmia purely local — wherein, at least, no marks of general febrile ac-
tion were manifested — in which topical evacuations by cups and leeches
being altogether insufficient for the purposes of a cure, general blood-let-
ting was copiously and very advantageously employed. In these instances it
was necessary to enforce the antiphlogistic regimen with the utmost strict-
ness, and to carry it to a greal extent. The entire exclusion of light
and the prevention of all conversation are alike essential to successful prac-
tice.

In cases where fever does prevail, there are none of the phlegmasia; that
require more copious evacuations, or a more vigorous treatment than oph-
thalmia. Until the disease be completely cured relapses are very easily pro-
duced All indulgences, therefore, and every exposure should be strictly
prohibited.

The repeated division of the turgid vessels of the adnata is a remedy use-
ful, perhaps, in all cases; but indispensable where opake spots appear on
the cornea. There exists, we believe, no other method whereby such
spots can be so completely removed ; that which is here recommended de-
stroying the channels that convey to them their nourishment.

PRACTICE OF PHYSIC. 231

off the determination of the fluids to it, blistering near
the part has commonly been found useful.

285. Electrical sparks taken from the eye will often
suddenly discuss the inflammation of the adnata; but
the effect is seldom permanent, and even a frequent re-
petition seldom gives an entire cure.

286. Ophthalmia, as an external inflammation, ad-
mits of topical applications. All those, however, that
increase the heat and relax the vessels of the part, prove
commonly hurtful; and the admission of cool air to the
eye, the proper application of cold water immediately to
the ball of the eye, and the application of various cooling
and astringent medicines, which at the same time do not
produce much irritation, prove generally useful: even
spirituous liquors, employed in moderate quantity, have
often been of service.*

287. In the cure of Ophthalmia much care is requi-
site to avoid all irritation, particularly that of light;
and the only safe and certain means of doing this is by
confining the patient to a very dark chamber.

288. These are the remedies of the Ophthalmia mem-
branarum; and in the Ophthalmia tarsi, so far as it is
produced by Ophthalmia membranarum, the same re-
medies may be necessary. As, however, the Ophthal-
mia tarsi may often depend upon an acrimony deposited
in the sebaceous glands of the part, so it may require
various internal remedies according to the nature of the
acrimony in fault ; for which I must refer to the con-

* When the eye is highly infamed, cold applications to it are injurious.
They should never be employed, therefore, until, by other remedies, the
inflammation is considerably reduced. Under the erroneous belief that
cold is a sedative, we are persuaded that its premature application in the
treatment of Ophthalmia has done much mischief. So has the too early use
of solutions of saccharum saturni, white vitriol, and other astringent lotions.
When inflammation is violent, such remedies are inadmissible. An excel-
lent application to an inflamed eye is, the fine mucus produced by infus-
ing the pith of sassafras in water.

232 PRACTICE OF PHYSIC.

sideration of scrofula, syphilis, or other diseases with
which this Ophthalmia may be connected; and when
the nature of the acrimony is not ascertained, certain
remedies, more generally adapted to the evacuation of
acrimony, such, for instance, as mercury, may be em-
ployed.*

289. In the Ophthalmia tarsi, it almost constantly
happens that some ulcerations are formed on the tarsus.
These require the application of mercury or copper,
either of which may by itself sometimes entirely cure
the affection; and these may even be useful when the
disease depends upon a fault of the whole system.

290. Both in the Ophthalmia membranarum, and in
the Ophthalmia tarsi, it is necessary to obviate that glu-
ing or sticking together of the eyelids which commonly
happens in sleep; and this may be done by insinuating
a little of any mild unctuous medicine, of some tena-
city, between the eyelids before the patient shall go to
sleep.

CHAPTER IV.
OF PHRENSY, OR PHRENITIS.

291. THIS disease is an inflammation of the parts con-
tained in the cavity of the cranium; and may affect
either the membranes of the brain, or the substance of
the brain itself. Nosologists have apprehended, that
these two cases might be distinguished by different

* In this description of Ophthalmia, we have often, with great relief and
permanent advantage to our patients, prescribed the use of the ungnentum
citrinum. The unguentum tutiae, and the unguentum cerussae acetatx are
also serviceable. For the proper time of using them, the practitioner must
rely onhis own judgment.

In chronic Ophthalmia, laudanum in water, or a mixture of a watery solu-
tion of opium, and an infusion of Spanish galls, is a very useful remedy.

PRACTICE OF. PHYSIC. 233

symptoms, and therefore by different appellations: but
this does not seem to be confirmed by observation and
dissection; and therefore I shall treat of both cases
under the title of Phrensy, or Phrenitis.

292. An idiopathic phrensy is a rare occurrence, a
sympathetic more frequent; and the ascertaining either
the one or the other is, upon many occasions, difficult.
Many of the symptoms by which the disease is most
commonly judged to be present, have appeared, when,
from certain considerations, it was presumed, and even
from dissection it appeared, that there had been no in-
ternal inflammation; and on the other hand, dissections
have shown, that the brain had been inflamed, when few
of the peculiar symptoms of phrensy had before ap-
peared*

293. The symptoms by which this disease may be
most certainly known, are a vehement pyrexia, or a vio-
lent deep-seated headach, a redness and turgescence of
the face and eyes, an impatience of light and noise, a
constant watching, and a delirium impetuous and furi-
ous. Some nosologists have thought these symptoms
peculiar to an inflammation of the membranes, and that
the inflammation of the substance of the brain was to be
distinguished by some degree of coma attending it. It
was for this reason that in the Nosology I added the
Typhomania to the character of Phrenitis; but upon

* Unless where it arises from mechanical violence, we believe that cere-
bral inflammation has always its original seat in the stomach — at least in
some part of the alimentary canal. Hence the advantages of copious purging - . '
Where no mechanical violence has been offered, we do not perceive how the
brain can be originally assailed. Besides, tracts of country wherein bilious
fever prevails, are most remarkable for phrenitic affections.

The coup de soleil, or stroke of the sun, is not an original affection of the
brain. It is a form of gastric disease — i. e. bilious fever. The brain is too
well guarded to be primarily affected by the rays of the sun. Those agents,
subtle and penetrating as they are, can reach it only through the medium of
sympathy.

VOL. I. G g

234 PRACTICE OF PHYSIC.

further reflection, I find no proper foundation for this;
and if we pass from the characters above delivered,
there will be no means of fixing the variety that occurs.

I am here, as in other analogous cases, of opinion,
that the symptoms above mentioned of an acute inflam-
mation, always mark inflammations of membranous
parts; and that an inflammation of the parenchyma or
substance of v iscera, exhibits, at least commonly, a more
chronic affection.

294. The remote causes of phrensy, are all those
which directly stimulate the membranes or substance of
the brain: and particularly all those which increase the
impetus of the blood in the vessels of the brain. Among
these the exposure of the naked head to the direct rays
of a xery warm sun is a frequent cause. The passions
of the mind, and certain poisons, are amongst the re-
mote causes of phrensy; but in what manner they ope-
rate is not well understood.

295. The cure of phrensy is the same with that of
inflammation in general; but in phrensy the most pow-
erful remedies are to be immediately employed. Large
and repeated blood-letting is especially necessary; and
the blood should be drawn from vessels as near as possi-
ble to the part affected. The opening of the temporal
artery has been recommended, and with some reason;
but the practice is attended with inconvenience; and I
apprehend that opening the jugular veins may prove
more effectual; but at the same time, it will be gene-
rally proper to draw blood from the temples by cupping
and scarifying.

296. It is probable, that purging, as it may operate
by revulsion, may be of more use in this than in some
other inflammatory affections.

For the same purpose of revulsion, warm pediluvia
are a remedy; but at the same time somewhat ambigu-

PRACTICE OF PHYSIC. 235

ous. The taking off the force of the blood in the ves-
sels of the head by an erect posture, is generally use-
ful.*

297. Shaving of the head is always proper and ne-
cessary for the admission of other remedies. Blister-
ing is commonly useful in this disease, but chiefly when
applied near the part affected.f

298. Every part of the antiphlogistic regimen is here
necessary, and particularly the admission of cold air.
Even cold substances, applied close to the head, have
been found safe and highly useful; and the application
of such refrigerants as vinegar, is certainly proper. J

299. It appears to me certain, that opiates are hurt-
ful in every inflammatory state of the brain; and it is to
be observed, that, from the' ambiguity mentioned in
(292.) the accounts of practitioners, with regard to the
juvantia and laedentia in this disease, are of very un-
certain application.

chapter v.

OF THE QUINSY, OR CYNANCHE.

300. THIS name is applied to every inflammation of
the internal fauces; but these inflammations are differ-
ent, according to the part of the fauces which may be

* Profuse purging is highly useful in phrenilic affections. The most ac-
tive and even drastic purges should be employed.

f That they may produce their full effect, blisters should be permitted to
remain on the head at least forty-eight hours, or even longer.

t The most convenient and effectual method of applying cold to phr»*nitic
patients, is to cover the head by bladders filled with pounded ice. When
permanently applied, this proves a remedy of great effect

Digitalis, in substance or tincture, taken until it has produced its peculiar
effect on the pulse, is said to be highly useful in phrenitis.

236 PRACTICE OF PHYSIC.

affected, and according to the nature of the inflamma-
tion. In the Nosology, therefore, after giving the cha-
racter of the Cynanche as a genus, I have distinguish-
ed five different species, which must here likewise be
separately considered.

Sect. I. — Of the Cynanche Tonsillaris.

301. This is an inflammation of the mucous mem-
brane of the fauces, affecting especially that congeries
of mucous follicles which forms the tonsils, and spread-
ing from thence along the velum and uvula, so as fre-
quently to affect every part of the mucous membrane.

302. The disease appears by some tumour, some-
times considerable, and by a redness of the parts; is at-
tended with a painful and difficult deglutition; with a
pain sometimes shooting into the ear; with a trouble-
some clamminess of the mouth and throat; with a fre-
quent, but difficult, excretion of mucus; and the whole
is accompanied with a pyrexia*

303. This species of quinsy is never contagious. It
terminates frequently by resolution, sometimes by sup-
puration, but hardly ever by gangrene; although in this
disease some sloughy spots, commonly supposed to be
forerunners of gangrene, sometimes appear upon the
fauces.

304. This disease is commonly occasioned by cold
externally applied, particularly about the neck. It af-
fects especially the young and sanguine, and a disposi-

* Some of the most excruciating affections of the ear we have ever wit-
nessed have arisen from this complaint. A blister on the throat has rarely-
failed to afford relief.

We believe that the pain in the ear, from which many children suffer so
much, is almost uniformly connected either with a carious tooth or an in-
flammation of the tonsils. To these sources, therefore, practitioners will do
well to direct their attention.

PRACTICE OF PHYSIC. 037

tion to it is often acquired by habit; so that from every
considerable application of cold to any part of the body,
this disease is readily induced. It occurs especially in
spring and autumn, when vicissitudes of heat and cold
frequently take place. The inflammation and tumour
are commonly at first most considerable in one tonsil;
and afterwards abating in that, increase in the other.

305. In the cure of this inflammation, some bleed-
ing may be proper: but large general bleedings will sel-
dom be necessary. The opening of the ranular veins
seems to be an insignificant remedy; and leeches set
upon the external fauces are of more efficacy.

306. At the beginning of the disease, full vomiting
has been frequently found to be of great service.

307. This inflammation may be often relieved by
moderate astringents, and particularly by acids applied
to the inflamed parts. In many cases, however, no-
thing has been found to give more relief than the
vapour of warm water received into the fauces by a
proper apparatus.*

308. The other remedies of this disease are rubefa-
cient or blistering medicines, applied externally to the
neck; and with these, the employment of antiphlogistic
purgatives, as well as every part of the antiphlogistic
regimen, excepting the application of cold.

309. This disease, as we have said, often terminates
by resolution, frequently accompanied with sweating;

* Simple water, or sage tea, acidulated with vinegar artd sweetened with
honey, makes an excellent gargarism in this disease. The addition of alum
or nitre is thought to render the remedy more efficacious.

Decoctions of oak bark, and solutions of carbonate of ammonia are also
recommended; whatever increases the secretion from the part affected, by
exciting action in the vessels, appears to be useful: for, here, as in other
cases of topical infiammation, there exists a remora in the fluids, occasioned
by a deficiency of vascular action.

238 PRACTICE OF PHYSIC.

which is therefore to be prudently favoured and en
couraged.*

310. When this disease shall have taken a tendency
to suppuration, nothing will be more useful, than the
frequent taking into the fauces the steams of warm
water. When the abscess is attended with much swell-
ing, if it break not spontaneously, it should be opened
by a lancet: and this does not require much caution, as
even the inflammatory state may be relieved by some
scarification of the tonsils.

I have never had occasion to see any case requiring
bronchotomy.f

Sect. II. — Of the Cynanche Maligna.

311. This is a contagious disease, seldom sporadic,
and commonly epidemic. It attacks persons of all ages,
but more commonly those in a young and infant state.
It attacks persons. of every constitution when exposed
to the contagion, but most readily the weak and infirm. J

* We have never perceived much advantage to be derived from sweating
in this disease. In the treatment of topical inflammation, the discharge by
the skin is a feeble remedy, and should never be suffered to stand in the
way of such as are active.

Bleeding, general!} and locally, purging, gargling and blistering are the
remedies on which, in their treatment of this disease, practitioners of expe-
rience principally rely.

-j- In addition to the steams of warm water, which may be conveniently
received from Mudge's or any other inhaler, warm poultices and fomenta-
tions applied externally to the region of the fauces, are recommended as
useful in promoting the suppuration of the tonsils. Nor ait- the) without
their effect in relieving pain. Their employment, therefore, ought not to
be neglected.

\ From such observations as we have had an opportunity of making, we
have no ground to consider cynanche maligna aa a contagious disease. Its
attacking a number of persons at once, or in succession,in the same family or
neighbourhood, affords no proof that it is so ; yet this is all the evidence
that can be collected on the subject

We believe it to be entirely an atmospheric complaint ; and that it pre-
vails as an epidemic, because all persons hold intercourse with the atmo-

PRACTICE OF PHYSIC. 239

312. This disease is usually attended with a consider-
able pyrexia; and the symptoms of the accession of this,
such as frequent cold shiverings, sickness, anxiety, and
vomiting, are often the first appearances of this disease.
About the same time, a stiffness is felt in the neck, with
some uneasiness in the internal fauces, and some hoarse-
ness of the voice. The internal fauces, when viewed,
appear of a deep red colour, with some tumour; but
this last is seldom considerable, and deglutition is sel-
dom difficult or painful. Very soon a number of white
or ash-coloured spots appear upon the inflamed parts.
These spots spread and unite, covering almost the whole
fauces with thick sloughs; which falling off, discover
ulcerations. While these symptoms proceed in the
fauces, they are generally attended with a coryza which
pours out a thin acrid and fetid matter, excoriafing the
nostrils and lips. There is often also, especially in in-
fants, a frequent purging: and a thin acrid matter flows
from the an us,excoriating this and the neighbouring parts.

313. With these symptoms, the pyrexia proceeds
with a small, frequent, and irregular pulse; and there
occurs a manifest exacerbation every evening, and
some remission in the mornings. A great debility ap-
pears in the animal functions; and the sensorium is
affected with delirium, frequently with coma.

314. On the second day, or sometimes later, efflores-
cences appear upon the skin, which are sometimes in
small points hardly eminent; but, for the most part, in

sphere, the source through which its poison is diffused, and from which it is
received into the human body.

We are persuaded thai its original seat is in the stomach, and that the
ulceration of the throat is but a secondary affection. Hence the importance
of emetics, administered in the early stages of the disease

Cuticular eruptions, accompanied with fever, proceed almost uniformly
from a disordered stomach. Beside*, in the treatment of cynanche maligna,
it is to the stomach alone that the principal and most important remedies are
directed. Those applied to the throat are, at best, but palliative.

240 PRACTICE OF PHYSIC

patches of a red colour, spreading and uniting so as to
cover the whole skin. They appear first about the face
and neck, and in the course of some days spread by
degrees to the lower extremities. The scarlet redness
is often considerable on the hands and extremities of
the fingers, which feel stiff and swelled. This eruption
is often irregular, as to the time of its appearance, as to
its steadiness, and as to the time of its duration. It
usually continues four days, and goes off by some
desquamation of the cuticle; but neither on its first ap-
pearance, nor on its desquamation, does it always pro-
duce a remission of the pyrexia, or of the other symp-
toms.

315. The progress of the disease depends on the state
of the fauces and of the pyrexia. When the ulcers on
the fauces, by their livid and black colour, by the fetor
of the breath, and by many marks of acrimony in the
fluids, show a tendency to gangrene, this takes place to
a considerable degree; and the symptoms of a putrid
fever constantly increasing, the patient dies, often on the
third day, sometimes later, but for the most part before
the seventh. The acrimony poured out from the diseased
fauces must necessarily, in part, pass into the pharynx,
and there spread the infection into the oesophagus, and
sometimes through the whole of the alimentary canal,
propagating the putrefaction, and often exhausting the
patient by a frequent diarrhoea.

The acrid matter poured out in the fauces being again
absorbed, frequently occasions large swellings of the
lymphatic glands about the neck, and sometimes to such
a degree as to occasion suffocation.

It is seldom that the organs of respiration escape
entirely unhurt, and very often the inflammatory affection
is communicated to them. From dissections it appears,
that, in the Cynanche maligna, the larynx and trachea are

PRACTICE OF PHYSIC. 241

often affected in the same manner as in the Cynanche
tracbealis; and it is probable, that, in consequence of
that affection, the Cynanche maligna often proves fatal
by such a sudden suffocation as happens in the proper
Cynanche trachealis; but there is reason to suspect,
that upon this subject dissectors have not always dis-
tinguished properly between the two diseases.*

316. These are the several fatal terminations of the
Cynanche maligna; but they do not always take place.
Sometimes the ulcers of the fauces are of a milder
nature, and the fever is more moderate, as well as of a
less putrid kind. And when, upon the appearance of
the efflorescence on the skin, the fever suffers a remis-
sion; when the efflorescence continues for three or four
days, till it has spread over the whole body, and then
ends by a desquamation, giving a further remission of
the fever; this often entirely terminates, by gentle sweats,
on or before the seventh day; and the rest of the dis-
ease terminates in a few days more, by an excretion of
sloughs from the fauces; while sleep, appetite, and the
other marks of health return.

From what is said in this and the preceding para-
graph, the prognostics in this disease may be readily
learned.

317. In the cure of this disease, its septic tendency
is chiefly to be kept in view. The debility, with which

* This is a mistake. The progress of the disease corresponds with " the
state of the fauces," but depends on that of the stomach, which regulates both
the pyrexia and every other symptom appertaining to the complaint.

Although the matter discharged from the ulcers in the throat must, if
swallowed, necessarily tend to aggravate the disease, it is not to be regard-
ed as the cause of the diarrhoea, which frequently marks its latter stages.
That affection more properly arises from the injury done to the stomach
and bowels, by the poison that originally produces the complaint. In the
mean time, however, great care should be taken that the ulcerous matter
from the throat do not find its way into the oesophagus.

VOL. I. H h

2&2 PRACTICE OF PHYSIC.

it is attended, renders all evacuations by bleeding and
purging improper, except in a few instances where the
debility is less, and the inflammatory symptoms more
considerable. The fauces are to be preserved from
the effects of the acrid matter poured out upon them,
and are therefore to be frequently washed out by anti-
septic gargles or injections; and the septic tendency of
the whole system should be guarded against and cor-
rected by internal antiseptics, especially by the Peru-
vian bark, given in substance, from the beginning, and
continued through the course of the disease. Emetics,
both by vomiting and nauseating, prove useful, espe-
cially when employed early in the disease. When any
considerable tumour occurs, blisters applied externally
will be of service, and in any case may be fit to mode-
rate the internal inflammation.*

* For the treatment of this disease the indications are plain. They are,
to keep clean the alimentary canal, to give strength and tone to the system,
and to determine to the skin. The first of these is to be answered by eme-
tics and purgatives, so far as they may be used with safety, and by gargles :
the second, by bark, wine, the mineral acids, and other articles stimulating
and cordial : and the third, by sudorifics and blisters.

In addition to this, perfect cleanliness ought to be preserved, by frequently
changing the bed and body clothes, ventilating the chamber, but not with
cold or damp air, removing from it promptly all excrementitious matters,
and diffusing occasionally through its atmosphere the fumes of vinegar, or
portions of nitrous or muriatic acid gas.

Children and young people being more frequently the subjects of this
disease than adults, it is impracticable, for the most part, to induce them to
swallow a sufficient quantity of the bark. In such cases, that remedy should
be administered in the form of injection, suspended in mucilage of gum
arabic, and united with laudanum, or a watery solution of opium, to prevent
it from being discharged.

It is scarcely necessary to observe, that to produce a given effect, the
quantity of any medicine administered by injection, must be nearly fourfold
that which would be administered by the mouth.

Great care should be taken to keep in check, by opiates and astringents,
the diarrhcen, which is apt to prove troublesome towards the close of this
disease.

PRACTICE OF PHYSIC. 243

Sect. III. — Of Cynanche Trachealis.

3 IS. This name has been given to an inflammation
of the glottis, larynx, or upper part of the trachea, whe-
ther it affect the membranes of these parts, or the mus-
cles adjoining. It may arise first in these parts, and con-
tinue to subsist in them alone; or it may come to affect
these parts from the Cynanche tonsillaris or maligna
spreading into them.*

319. In either way it has been a rare occurrence,
and few instances of it have been marked and recorded
by physicians. It is to be known by a peculiar ringing
sound of the voice, by difficult respiration, with a sense
of straitening about the larynx, and by a pyrexia at-
tending it.

320. From the nature of these symptoms, and from
the dissection of the bodies of persons who had died of
this disease, there is no doubt of its being of an inflam-
matory nature. It does not, however, always run the
course of inflammatory affections, but frequently pro-
duces such an obstruction of the passage of the air,
as suffocates, and thereby proves suddenly fatal.

321. If we judge rightly of the nature of this dis-
ease, it will be obvious that the cure of it requires the
most powerful remedies of inflammation to be employed
upon the very first appearance of the symptoms. When
a suffocation is threatened, whether any remedies can

* We believe Cynanche Trachealis to be always an original disease, and
never produced by any irregularities in Cynanche tonsillaris, or Cynanche ma-
ligna.

It is not, as our author alleges, a disease of " rare occurrence." In the
United States, at least, it occurs very frequently. It is described by Dr.
Boerhaave, in Aphorisms 801 and 802. Dr. Home, of Edinburgh, as Dr.
Culle'n observes, was the first who gave us a correct idea of its nature.

244 PRACTICE OF PHYSIC.

be employed to prevent it, we have not had experience
to determine.

322. The accounts which books have hitherto given
us of inflammations of the larynx, and the parts con-
nected with it, amount to what we have now said; and
the instances recorded have almost all of them happened
in adult persons: but there is a peculiar affection of this
kind happening especially to infants, which till lately
has been little taken notice of. Dr. Home is the first
who has given any distinct account of it; but, since he
wrote, several other authors have taken notice of it, (see
Michaelis De angina polyposa sive membranacea, Jlr-
genlwati 1773) and have given different opinions with
regard to it. Concerning this diversity of opinions I
shall not at present inquire; but shall deliver the history
and cure of this disease, in so far as these have arisen
from my own observation, from that of Dr. Home, and
of other skilful persons in this neighbourhood.

323. This disease seldom attacks infants till after
they have been weaned. After this period, the younger
they are, the more they are liable to it. The frequency
of it becomes less as children become more advanced;
and there are no instances of children above twelve years
of age being affected with it. It attacks children of the
midland countries, as well as those who live near the
sea. It does not appear to be contagious, and its attacks
are frequently repeated in the same child. It is often
manifestly the effect of cold applied to the body; and
therefore appears most frequently in the winter and
spring seasons. It very commonly comes on with the
ordinary symptom of a catarrh; but sometimes the pe-
culiar symptoms of the disease show themselves at the
very first*

* It may, perhaps, be true, that Cynanche trachealis is more incidental to
children after they are weaned than before ; but it attacks them frequently

PRACTICE OF PHYSIC. 245

S24. These peculiar symptoms are the following: A
hoarseness, with some shrillness and ringing sound,
hoth in speaking and coughing, as if the noise came
from a brazen tube. At the same time, there is a sense
of pain about the larynx, some difficulty of respiration,
wil'i a whizzing sound in inspiration, as if the passage
of the air were straitened. The cough which attends it
is commonly dry; and if any thing be spit up, it is a
matter of a purulent appearance, and sometimes films
resembling portions of a membrane. Together with
these symptoms, there is a frequency of pulse, a rest-
lessness, and an uueasy sense of heat.

When the internal fauces are viewed, they are some-
times without any appearance of inflammation: but fre-
quently a redness and even swelling appear; and some-
times in the fauces there is an appearance of matter
like to that rejected by coughing. With the symptoms
now described, and particularly with great difficulty of
breathing, and a sense of strangling in the fauces, the
patient is sometimes suddenly taken off.

325. There have been many dissections made of in-
fants who had died of this disease; and almost constantly
there has appeared a preternatural membrane lining the
whole internal surface of the upper part of the trachea,

at every period, from the age of three months to that of six or seven years.
At a later period we have rarely seen it.

Although this disease often, perhaps always, when in a sporadic form, arises
from improper exposure to cold or humidity, and is, therefore, connected
with changes in the weather; it, notwithstanding, like other diseases, pre-
vails, at times, as an epidemic, without any apparent dependence on the
sensible qualities of the atmosphere.

This appears to have been the case in the neighbourhood of Alexandria,
in Virginia, in the year 1799, the period at which General Washington fell
a victim to it ; and it was certainly the case in Philadelphia in the winter of
of 1809-10, when the disease was productive of considerable mortality. On
the latter occasion, we know, from observation, that the weather was regu-
lar and pleasent for the season ; yet, for several weeks, the croup prevailed
with the character of an epidemic; and we are informed on authority, which
we cannot question, that the same thing is true in relation to the former.

246 PRACTICE OF PHYSIC.

and extending in the same manner downwards into
some of its ramifications. This preternatural mem-
brane may be easily separated, and sometimes has been
found separated in part from the subjacent proper
membrane of the trachea. This last is commonly
found entire, that is, without any appearance of erosion
or ulceration; but it frequently shows the vestiges of
inflammation, and is covered by a matter resembling
pus, like to that rejected by coughing; and ven often
a matter of the same kind is found in the bronchiae,
sometimes in considerable quantity.*

326. From the remote causes of this disease; from
the catarrhal symptoms commonly attending it; from
the pyrexia constantly present with it; from the same
kind of preternatural membrane being found in the
trachea when the cynanche maligna is communicated
to it; and, from the vestiges of inflammation on the tra-
chea discovered upon dissection; we must conclude,
that the disease consists in an inflammatory affection
of the mucous membrane of the larynx and trachea,
producing an exudation analogous to that found on the

* In the dissections made in this country — and they have been numerous
— this preternatural membrane in the trachea and bronchia: has rarely been
found. In many, perhaps a majority of cases, but very little even of com-
mon mucus, or of any thing else that marks inflammation, has been found in
the neighbourhood of the seat of the disease. We have the high authority
of our very able and distinguished friend, the present professor of the the-
ory and practice of medicine in the university of Pennsylvania, to say, that
such has been the result of his experience. Such has been, in like manner,
the result of our own. Yet the disease is, for the most part, if not always,
of an inflammatory character, and we are bound to believe, that the mem-
brane does occasionally exist.

We are persuaded that, in some of the worst cases, the local disease con-
sists principally in a violent spasmodic affection of the muscles of the glottis
and those in their neighbourhood. This spasm arises from the increased ir-
ratability of these muscles, in consequence of the inflammation with which
they are affected. In such instances, were mucus secreted into the trachea
the complaint would be relieved, as occurs in catarrh, pneumonia, and other
diseases of an inflammatory type.

PRACTICE OF PHYSIC. 247

surface of inflamed viscera, and appearing partly in
a membranous crust, and partly in a fluid resembling
pus.

327. Though this disease manifestly consists in an
inflammatory affection, it does not commonly end either
in suppuration or gangrene. The peculiar and trouble-
some circumstance of the disease seems to consist in a
spasm of the muscles of the glottis, which, by inducing
a suffocation, prevents the common consequences of
inflammation.

328. When this disease terminates in health, it is by
a resolution of the inflammation, by a ceasing of the
spasm of the glottis, by an expectoration of the matter
exuding from the trachea, and of the crusts formed
there; and frequently it ends without any expectoration,
or at least with such only as attends an ordinary ca-
tarrh.

329. When the disease ends fatally, it is by a suffo-
cation; seemingly, as we have said, depending upon a
spasm affecting the glottis; but sometimes, probably,
depending upon a quantity of matter filling the bron-
chiae.

330. As we suppose the disease to be an inflamma-
tory affection, so we attempt the cure of it by the usual
remedies of inflammation, and which for the most part
I have found effectual. Bleeding, both general and
topical, has often given immediate relief; and by being
repeated, has entirely cured the disease. Blistering
also, near to the part affected, has been found useful.
Upon the first attack of the disease, vomiting immedi-
ately after bleeding, seems to be of considerable use,
and sometimes suddenly removes the disease. In every
stage of the disease, the antiphlogistic regimen is ne-
cessary, and particularly the frequent use of laxa-
tive glysters. Though we suppose that a spasm af-

248 PRACTICE OF PHYSIC.

fecting the glottis is often fatal in this disease, I have not
found antispasmodic medicines to be of any use.*

Sect. IV. — Of Cynanche Pharyngcea.

331. In the Cynanche tonsillaris, the inflammation
of the mucous membrane often spreads upon the pha-
rynx, and into the beginning of the oesophagus, and
thereby renders deglutition more difficult and uneasy;
but such a case does not require to be distinguished as
a different species from the common Cynanche tonsil-
laris; and only requires that blood-letting, and other re-
medies, should be employed with greater diligence
than in ordinary cases. We have never seen any case
in which the inflammatiou began in the pharynx, or in
which this part alone was inflamed; but practical wri-
ters have taken notice of such a case; and to them,
therefore, I must refer, both for the appearances which
distinguish it, and for the method of cure.

* The remedies for this disease are blood-letting, carried sometimes to *
very considerable extent, severe and repeated vomiting - , purging - and blis-
tering. Although these are all proper and necessary, vomiting we con-
sider as the most important ; and tartarized antimony the most suitable arti-
cle by which it can be produced. Besides diminishing arterial action, and
thereby weakening the existing spasm, it determines to the skin, and dis-
charges such troublesome and offending mucus as may be collected in the
trachea. To excite puking in this disease, Cox's Hive Syrup (for which
see his Dispensatory) is an efficacious remedy. Tincture of Digitalis given
so as to produce sickness and nausea, is recommended as useful. W T e have
never witnessed its effects.

We usually exhibit in this disease, and, as we think, with great advantage,
tartarized antimony combined with calomel, that the stomach, skin and bow-
els, the three principal seats of excitement and sympathy, may be acted on
at once. Of antimony given in nauseating doses, we have never witnessed
the good effects.

In protracted cases, where debility is great, and vomiting, therefore, in-
admissible, we have administered, with success, a strong decoction of the
Seneca root.

Blisters applied to the throat should be kept open during the continuance
•f the disease. When managed in this way they are useful.

PRACTICE OF PHYSIC. 249

Sect. V. — Of the Cynanche Parotidcea.

332. This is a disease known to the vulgar, and
among them has got a peculiar appellation, in almost
every country in Europe; but has been little taken no-
tice of by medical writers. It is often epidemic, and
manifestly contagious. It comes on with the usual
symptoms of pyrexia, which is soon after attended with
a considerable tumour of the external fauces and neck.
This tumour appears first as a glandular moveable tu-
mour at the corner of the lower jaw; but the swelling
soon becomes uniformly diffused over a great part of
the neck; sometimes on one side only; but more com-
monly on both. The swelling ccntinues to increase
till the fourth day; but from that period it declines, and
in a few days more passes off entirely. As the swell-
ing of the fauces recedes, some tumour affects the tes-
ticles in the male sex, or the breasts in the female.
These tumours are sometimes large, hard, and some-
what painful; but in this climate are seldom either very
painful or of long continuance. The pyrexia attend-
ing this disease is commonly slight, and recedes with
the swelling of the fauces; but sometimes, when the
swelling of the testicles does not succeed to that of the
fauces, or when the one or the other has been suddenly
repressed, the pyrexia becomes more considerable, is
often attended with delirium, and has sometimes proved
fatal*

* In relation to Cynanche Parotidxa we have only to observe, that we
consider it an atmospheric and epidemic, rather than a contagious disease.
Like other epidemics, it pervades families, towns, and tracts of country ; but
we have nothing to convince us that it passes by contagion from the sick to
the well. We have seen but few cases of it that actually required medical
aid. In these few, the remedies we have employed have been such as are
usual in inflammatory complaints— blood-letting and purging, and occa-
VOL. I. T i

250 PRACTICE OF PHYSIC.

333. As this disease commonly runs its course with-
out either dangerous or troublesome symptoms, so it
hardly requires any remedies. An antiphlogistic regi-
men and avoiding cold, are all that will be commonly
necessary. But when, upon the receding of the swell-
ings of the testicles in males, or of the breasts in fe-
males, the pyrexia comes to be considerable, and
threatens an affection of the brain, it will be proper,
by warm fomentations, to bring back the swelling; and
by vomiting, bleeding, or blistering, to obviate the con-
sequences of its absence.

CHAPTER VI.

OF PNEUMONIA, OR PNEUMONIC INFLAMMATION.

334. UNDER this title I mean to comprehend the
whole of the inflammations affecting either the viscera
of the thorax, or the membrane lining the interior sur-
face of that cavity: for neither do our diagnostics serve
to ascertain exactly the seat of the disease; nor does
the difference in the seat of the disease exhibit any
considerable variation in the state of the symptoms, nor
lead to any difference in the method of cure.

335. Pneumonic inflammation, however various in its
seat, seems to me to be always known and distinguish-
ed by the following symptoms: pyrexia, difficult breath-
ing, cough, and pain in some parts of thy thorax. But

sional puking and blistering, with the rigid enforcement of an antiphlogistic
regimen.

We have never witnessed an instance of mortality from this disease ; nor
have we seen many cases wherein was experienced any serious inconveni-
ence by a translation of the inflammation to the testicles in males, or the
breasts in females. As often as this accident has occurred in our practice,
it has been in the persons of adults. It calls for a strict observance of the
antiphlogistic regimen ; and generally yields to that without difficulty.

PRACTICE OF PHYSIC. 25\

these symptoms are, on different occasions, variously
modified.

336. The disease almost always comes on with a cold
stage, and is accompanied with the other symptoms of
pyrexia; though, in a few instances, the pulse may not
be more frequent, nor the heat of the body increased
beyond what is natural. Sometimes the pyrexia is from
the beginning accompanied with the other symptoms;
but frequently it is formed for some hours before the
other symptoms become considerable, and particularly
before the pain be felt. For the most part, the pulse is
frequent, full, strong, hard, and quick; but in a few in-
stances, especially in the advanced state of the disease,
the pulse is weak and soft, and at the same time irre-
gular.*

337. The difficulty of breathing is always present,
and most considerable in inspiration; both because the
lungs do not easily admit of a full dilatation, and be-
cause the dilatation aggravates the pain attending the
disease. The difficulty of breathing is also greater, when
the patient is in one posture of his body rather than
another. It is generally greater when he lies upon the
side affected; but sometimes the contrary happens.
Very often the patient cannot lie easy upon either side,
finding ease only when lying on his back; and some-
times he cannot breathe easily, except when in some-
what of an erect posture.f

* In a great majority of cases the pain is felt before the pyrexia, but is
seldom very severe until the pyrexia occurs.

A pulse is frequent, when the strokes are numerous in a given time ;
quick, when each stroke is performed in a very short time. In the phrase
*' a quick and frequent pulse," therefore, there is no tautology.

f The reason of this alternate increase and diminution of difficulty in
breathing is obvious. In inspiration the inflamed membrane or part is dis-
tended, but in expiration relaxed : and, we well know that, whether in the
thorax or elsewhere, distention is laborious and painful, and relaxation com-
paratively easy and grateful, to every part where inflammation prevail!.

252 PHACTIQE OL> PHYSIC.

338. A cough always attends this disease; but in dif-
ferent cases, is more or less urgent and painful. It is
sometimes dry, that is, without any expectoration, espe-
cially in the beginning of the disease; but more com-
monly it is, even from the first, moist, and the matter
spit up various both in consistence and colour; and fre-
quently it is streaked with blood.*

339. The pain attending this disease, is, in different
cases, felt in different parts of the thorax, but most fre-
quently in one side. It has been said to affect the right
side more frequently than the left; but this is not certain ;
while on the other hand, it is certain that the left side
has been very often affeqted. The pain is felt sometimes
as if it were under the sternum; sometimes in the back
between the shoulders; and when in the sides, its place
has been higher or lower, more forward or backward:
but the place of all others most frequently affected, is
about the sixth or seventh rib, near the middle of its
length, or a little more forward. The pain is often se-
vere and pungent; but sometimes more dull and obtuse,
with a sense of weight rather than of pain. It is most
especially severe and pungent when occupying the place
last mentioned. For the most part it continues fixed
in one place; but sometimes shoots from the side to the
scapula on one hand, or to the sternum and clavicle on
the other.

340. The varying state of symptoms now mentioned,
does not always ascertain precisely the seat of the dis-
ease. To me it seems probable, that the disease is al-
ways seated, or at least begins, in some parts of the
pleura; taking that membrane in its greatest extent, as

* In cases where the mucus discharged from the lungs is mixed with
blood, the practitioner cannot be too prompt in emptying the blood-vessels,
by means of venesection, as far as the other circumstances of the disease and
the state of the system will admit For a rupture of even the smallest
blood-vessel, in the lungs, ought to be suffered to heal as speedily and com-
pletely as possible.

PRACTICE OF PHYSIC. 253

now commonly understood; that is, as covering not only
the internal surface of the cavity of the thorax, but also
as forming the mediastinum, and as extended over the
pericardium, and over the whole surface of the lungs.

341. There is, therefore little foundation for distin-
guishing this disease by different appellations taken from
the part which may be supposed to be chiefly affected.
The term Pleurisy, might with propriety be applied to
every case of the disease; and has been very improperly
limited to that inflammation which begins in, and chiefly
affects the pleura costatis. I have no doubt that such
a case does truly occur; but, at the same time, I appre-
hend it to be a rare occurrence; and that the disease
much more frequently begins in, and chiefly affects, the
pleura investing the lungs, producing all the symptoms
supposed to belong to what has been called the Pleuri-
tis vera.

342. Some physicians have imagined that there is a
case of pneumonic inflammation particularly entitled to
the appellation of Peripneumony ; and that is, the case
of an inflammation beginning in the parenchyma or
cellular texture of the lungs, and having its seat chiefly
there. But it seems to be very doubtful, if any acute
inflammation of the lungs, or any disease which has been
called Peripneumony, be of that kind. It seems proba-
ble, that every acute inflammation begins in membran-
ous parts; and in every dissection of persons dead of
peripneumony, the external membrane of the lungs, or
some part of the pleura, has appeared to have been con-
siderably affected.

343. An inflammation of the pleura covering the up-
per surface of the. diaphragm, has been distinguished by
the appellation of Parapkrcnitis, as supposed to be at-
tended with the peculiar symptoms of delirium, risus
sardonicus, and other convulsive motions: but it is cer-

251 PRACTICE OF PHYSIC.

tain, that an inflammation of that portion of the pleura,
and affecting also even the muscular substance of the
diaphragm, has often taken place without any of these
symptoms; and I have not met with either dissections,
which support the opinion, that an inflammation of the
pleura covering the diaphragm, is attended with de-
lirium more commonly than any other pneumonic in-
flammation.*

344. With respect to the seat of pneumonic inflam-
mation, I must observe further, 4hat although it may
arise and subsist chiefly in one part of the pleura only,
it is however frequently communicated to other parts
of the same, and commonly communicates a morbid
affection through its whole extent.

345. The remote cause of pneumonic inflammation,
is commonly cold applied to the body, obstructing per-
spiration, and determining to the lungs; while at the
same time the lungs themselves are exposed to the ac-
tion of cold. These circumstances operate especially,
when an inflammatory diathesis prevails in the system;
and, consequently, upon persons of the greatest vigour;
in cold climates; in the winter season; and particularly
in the spring, when vicissitudes of heat and cold are
frequent. The disease, however, may arise in any sea-
son when such vicissitudes occur.

Other remote causes also may have a share in this
matter; such as every means of obstructing, straining,
or otherwise injuring the pneumonic organs.

Pneumonic inflammation may happen to persons in
any age, but rarely to those under the age of puberty:

* The proximity of the diaphragm to the stomach, and the probability of
its disordering that viscus, is the only reason, we apprehend, why ; an inflam-
mation of it should have any influence in the production of delirium. Be-
tween the diaphragm and the brain directly, we do not believe that much
sympathy subsists : but, between the stomach and the brain, the sympathy
is not only direct but powerful.

PRACTICE OF PHYSIC. 255

and most commonly it affects persons somewhat ad-
vanced in life, as those between forty-five and sixty
years ; those too, especially of a robust and full habit.

The pneumonic inflammation has been sometimes so
much an epidemic, as to occasion a suspicion of its de-
pending upon a specific contagion; but I have not met
with any evidence in proof of this.— See Morgagni
de causis et sedibus morborum, epist. xx. art. 26*

* Cold and humidity applied to the body act as the remote exciting cause
of peripneumony. But, inasmuch as this disease sometimes prevails as an
epidemic, it must have also a remote predisposing cause. This we must look
for in the insensible qualities of the atmosphere ; not in any vicissitudes of
its temperature or humidity. It is to be found in a peculiar atmospheric
constitution, creating an unusual liability to pneumonic inflammation.

Of the occasional existence of such a constitution we have abundant evi-
dence : and it is it, not contagiom that spreads peripneumony through fami-
■lies and neighbourhoods. During its prevalence, vicissitudes in the wea-
ther, and other causes, which, in common times, would do no mischief, excite
the disease in numerous instances. Such a constitution, in whatever it may
consist, is to peripneumony, what an atmosphere replete with marsh mias-
mata is to intermitting fever : it creates a predisposition to it, leaving nothing
necessary but an exciting cause to call it into action. Under the former
constitution, the same cause gives rise to a peripneumony, which, under the
latter, excites an intermittent.

To others of the phlegmasia: similar remarks may be applied. They too
prevail as epidemics, and, under such circumstances, depend on a peculiar
predisposing constitution of the atmosphere. By this constitution the seed
is sown in a suitable soil, and nothing is wanting but the necessary excite-
ment to awaken it into life.

Such is the case With influenza, scarlatina, hooping cough, and several
other complaints.

The doctrine of atmospheric constitutions is curious and interesting; and
has never yet been thoroughly investigated. It constitutes the philosophy of
epidemics, without which the principles of their propagation, and the laws
that govern them, can never be well understood.

To every epidemic, the constitution producing it stands related, as the
autumnal atmosphere of a marshy country docs to the various forms of bili-
ous fever ; as one of the essential conditions of its existence.

Peripneumony, when epidemic, is more malignant and dangerous than
when only sporadic. The reason is obvious. In the latter case it is brought
into existence by a tingle came,- in the former, by the combined and more
powerful operation of two. Besides, in every epidemic peripneumony we
have witnessed, the topical affection, instead of being strictly confined to
the thorax, has extended to some of the abdominal viscera ; more especially

25Q PRACTICE OF PHYSIC.

346. The pneumonic, like other inflammations, may
terminate by resolution, suppuration, or gangrene ; but
it has also a termination peculiar to itself, as has been
hinted above (259.) ; and that is, when it is attended with
an effusion of blood into the cellular texture of the
lungs, which soon interrupting the circulation of the
blood through this viscus, produces a fatal suffocation.
This, indeed, seems to be the most common termina-
tion of pneumonic inflammation, when it ends fatally;
for, upon the dissection of almost every person dead
of the disease, it has appeared that such an effusion had
happened.*

347. From these dissections also we learn, that pneu-
monic inflammation commonly produces an exudation
from the internal surface of the pleura, which appears
partly as a soft viscid crust, often of a compact, mem-
branous form, covering every where the surface of the
pleura, and particularly those parts where the lungs ad-
here to the pleura costalis, or mediastinum; and this
crust seems always to be the cement of such adhesions.
The same exudation shows itself also by a quantity
of a serous whitish fluid commonly found in the cavity
of the thorax; and some exudation or effusion is usually

•.he stomach and liver. Hence it oftentimes receives the denomination of
lilious pleurisy. But it is well known, that, as a general rule, abdominal in-
flammations are much more malignant and dangerous, than those that affect
only the viscera of the thorax.

Among the exciting causes of peripneumony may be enumerated, violent
exertions in speaking, singing, playing on wind instruments of music, or any
.kind of exertion that gives inordinate action to the lungs. To these may be
added, the breathing of air adulterated by an admixture of deleterious va-
pours; such as the fumes of arsenic, of sulphur, or of the muriatic acid. Let
chemists, therefore, in their experiments, and artists in their daily employ.
nients, beware of inhaling these aerial poisons.

* Dropsical effusion, in the form of hydrothorax or hydrops pericardii,
constitutes another mode in which pneumonic inflammation is known to ter
minate.

PRACTICE OF PHYSIC. 251

found to have been made likewise into the cavity of the
pericardium.*

348. It seems probable, too that a like effusion is
sometimes made into the cavity of the bronchiae: for,
in some persons who have died after labouring under a
pneumonic inflammation for a few days only, the bron-
chiae have been found filled with a considerable quan-
tity of a serous and thickish fluid; which, I think, must
be considered rather as the effusion mentioned, having
had its thinnest part taken off by respiration, than as a
pus so suddenly formed in the inflamed part.

349. It is, however, not improbable that this effusion,
as well as that made into the cavities of the thorax and
pericardium, may be a matter of the same kind with that
which, in other inflammations is poured into the cellu-
lar texture of the parts inflamed, and there converted
into pus; but, in the thorax and pericardium, it does not
always assume that appearance, because the crust co-
vering the surface, prevents the absorption of the thin-
ner part. This absorption, however, may be compen-
sated in the bronchia? by the drying power of the air;
and therefore the effusion into them may put on a more
purulent appearance.

In many cases of pneumonic inflammation, when the
sputa are very copious, it is difficult to suppose that the
whole of them proceed from the mucous follicles of the
bronchiae. It seems more probable that a great part of
them may proceed from the effused serous fluid we have
been mentioning, and this too will account for the sputa
being so often of a purulent appearance. Perhaps the
same thing may account for that purulent expectoration,
as well as that purulent matter found in the bronchiae,

• The appearances mentioned in this paragraph are nothing but those of
adhesive inflammation — another mode in which pneumonic inflammation
often terminates.

VOL. Ii K k

258 PRACTICE OF PHYSIC.

which the learned Mr. de Haen says he had often ob-
served, when there was no ulceration of the lungs: and
this explanation is at least more probable than M. de
Haen's supposition of a pus formed in the circulating
blood.*

350. To conclude this subject, it would appear, that
the effusion into the bronchiae which we have mention-
ed, often concurs with the effusion of red blood in occa-
sioning the suffocation, which fatally terminates pneu-
monic inflammation; that the effusion of serum alone
may have this effect; and that the serum poured out in
a certain quantity, rather than any debility in the powers
of expectoration, is the cause of that ceasing of expec-
toration which very constantly precedes the fatal event.
For, in many cases, the expectoration has ceased, when
no other symptoms of debility have appeared, and when,
upon dissection, the bronchiae have been found full of
liquid matter. Nay, it is even probable, that in some
cases such an effusion may take place, without any
symptoms of violent inflammation; and in other cases,
the effusion taking place may seem to remove the symp-
toms of inflammation which had appeared before, and
thus account for those unexpected fatal terminations
which have sometimes happened. Possibly this effu-
sion may account also for many of the phenomena of
the Peripneumonia Notha.

351. Pneumonic inflammation seldom terminates by
resolution, without being attended with some evident
evacuation. An hsemorrhagy from the nose happening
upon some of the first days of the disease, has some-
times put an end to it; and it is said that an evacuation

* Nothing: can be more replete with error, than our author's hypothesis
of the formation of pus, as stated in this paragraph. Indeed, for a man of
an observing, sound, and discriminating mind, most of his hypotheses are
exceedingly wild.

PRACTICE OF PHYSIC. 259

from the hemorrhoidal veins, a bilious evacuation by
stool, and an evacuation of urine with a copious sedi-
ment, have severally had the same effect: but such oc-
currences have been rare and unusual.

The evacuation most frequently attending, and seem-
ing to have the greatest effect in promoting resolution,
is an expectoration of a thick, white, or yellowish mat-
ter, a little streaked with blood, copious, and brought
up without either much or violent coughing.

Very frequently the resolution of this disease is at-
tended with, and perhaps produced by a sweat, which
is warm, fluid, copious over the whole body, and at-
tended with an abatement of the frequency of the pulse,
of th^ heat of the body, and of other febrile symptoms.*

352. The prognostics in this disease are formed from
observing the state of the principal symptoms.

A violent pyrexia is always dangerous.

The danger, however, is chiefly denoted by the diffi-
culty of breathing. When the patient can lie on one
side only; when he can lie on ueither side, but upon his
back only; when he cannot breathe with tolerable ease,
except the trunk of his body be erect; when, even in
this posture the breathing is very difficult, and attended
with a turgescence and flushing of the face, together
with partial sweats about the head and neck, and an ir-
regular pulse; these circumstances mark the difficulty
of breathing in progressive degrees, and, consequently,
in proportion, the danger of the disease.

* Bilious evacuations by stool, and an evacuation of urine with a copious
sediment, are concomitants, not causes of the resolution of pneumonic in-
flammation.

A secretion of mucus from the bronchi* shows, that the inflamed vessels,
which had been in a paralytic or powerless state, are now beginning to act,
and to relieve themselves of the superabundant portion of fluids which had
oppressed them.

260 PRACTICE OF PHYSIC.

A frequent violent cough aggravating the pain is al-
ways the symptom of an obstinate disease.

As I apprehend that the disease is hardly ever resolved,
without some expectoration : so a dry cough must be
always an unfavourable symptom.

As the expectoration formerly described, marks that
the disease is proceeding to a resolution; so an expecto-
ration which has not the conditions there mentioned,
must denote at least a doubtful state of the disease; but
the macks taken from the colour of the matter, are for
the most part fallacious.

An acute pain, very much interrupting inspiration, is
always the mark of a violent disease; though not of one
more dangerous, than an obtuse pain, attended with
very difficult respiration.

When the pains which at first had affected one side
only, have afterwards spread into the other; or when
leaving the side first affected, they entirely pass into the
other; these are always marks of an increasing, and,
therefore, of a dangerous disease.

A delirium coming on during a pneumonic inflam-
mation, is constantly a symptom denoting much danger.*

353. When the termination of this disease proves fa-
tal, it is on one or other of the days of the first week,
from the third to the seventh. This is the most com-
mon case; but in a few instances, death has happened
at a later period of the disease.

When the disease is violent, but admitting of resolu-
tion, this also happens frequently in the course of the

* In his prognosis generally, our author is correct, and well worthy of be-
ing attentively studied. But we cannot agree with him, that, when pneu-
monic pains, " leaving the side first affected, pass entirely into the other,"
this circumstance " marks a dangerous and increasing disease."

We think we have generally found a shifting of pneumonic pains to fur-
nish evidence of a manageable disease

PRACTICE OF PHYSIC. 261

first week; but, in a more moderate state of the disease,
the resolution is often delayed to the second week.

The disease, on some of the days, from the third to
the seventh, generally suffers a remission: which, how-
ever, may be often fallacious, as the disease does some-
times return again with as much violence as before, and
then with great danger.

Sometimes the disease disappears on the second or
third day, while an erysipelas makes its appearance on
some external part: and if this continue fixed, the pneu-
mouic inflammation does not recur.

354. Pneumonia, like other inflammations, often
ends in suppuration or gangrene.*

355. When a pneumonia, with symptoms neither very
violent nor very slight, have continued for many days,
it is to be feared it will end in a suppuration. This, how-
ever, is not to be determined precisely by the number
of days ; for, not only after the fourth, but even after the
tenth day, there have been examples of a pneumonia,
ending by a resolution; and if the disease has suffered
some intermission and again recurred, there may be
instances of a resolution happening at a much later
period from the beginning of the disease, than that just
now mentioned.!

356. But if a moderate disease, in spite of proper re-
medies employed, be protracted to the fourteenth day
without any considerable remission, a suppuration is

* The pathognomonic symptoms of incipient gangrene, are, relief from
pain, a purulent spitting streaked with deep coloured blood, or with a black-
ish matter; a fetid breath ; a rattling in the throat ; a dejected and languid
countenance; a dim eye; a feeble, quick, and frequent pulse; green, fetid
stools; and urine of a bright flame colour, or depositing a blackish flaky se-
diment.

f When a physician is called in within twenty-four, or even thirty-six
hours after the commencement o*" peripneumony, it is disgraceful to him
if he suffers it to terminate in suppuration. By proper evacuations, such an
event may be easily, and, we think we may add, with certainty, prevented.

262 PRACTICE OF PHYSIC.

pretty certainly to be expected; and it will be still more
certain, if no signs of resolution have appeared, or if an
expectoration which had appeared shall have again
ceased, and the difficulty of breathing has continued or
increased, while the other symptoms have rather abated.

357. That in a pneumonia, the effusion is made,
which may lay the foundation of a suppuration, we con-
clude from the difficulty of breathing becoming greater
when the patient is in a horizontal posture, or when he
can lie more easily upon the affected side.

358. That in such cases, a suppuration has actually
begun, may be concluded from the patient's being fre-
quently affected with slight cold shiverings, and with a
sense of cold felt sometimes in one, and sometimes in
another part of the body. We form the same conclusion
also from the state of the pulse, which is commonly
less frequent and softer, but sometimes quicker and
fuller than before.

359. That a suppuration is already formed, may be
inferred from there being a considerable remission of
the pain which had before subsisted, while along with
this, the cough, and especially the dyspnoea, continue,
and are rather augmented. At the same time, the fre-
quency of the pulse, is rather increased; the feverish
state suffers considerable exacerbations every evening,
and by degrees, a hectic, in all its circumstances, comes
to be formed.

360. The termination of pneumonia by gangrene, is
much more rare than has been imagined; and when it
does occur, it is usually joined with the termination by
effusion, (346.) and the symptoms of the one are hardly
to be distinguished from those of the other.

361. The cure of pneumonic inflammation, must pro-
ceed upon the general plan, (264.) but the importance of
the part affected, and the danger to which it is exposed.

PRACTICE OF PHYSIC. 268

require that the remedies be fully, as well as early em-
ployed.

362. The remedy chiefly to be depended upon, is
that of bleeding at the arm; which will be performed
with most advantage in the arm of the side most affect-
ed, but may be done in either arm, as may be most
convenient for the patient or the surgeon. The quantity
drawn must be suited to the violence of the disease, and
to the vigour of the patient; and generally ought to be
as large as this last circumstance will allow. The re-
mission of pain, and the relief of respiration, during the
flowing of the blood, may limit the quantity to be then
drawn; but if these symptoms of relief do not appear,
the bleeding should be continued till the symptoms of a
beginning syncope come on. It is seldom that one
bleeding, however large, will prove a cure of this dis-
ease ; and although the pain and difficulty of breathing
may be much relieved by the first bleeding, these symp-
toms commonly, and after no long interval, recur, often
with as much violence as before. In the event of such
recurrence, the bleeding is to be repeated, even in the
course of the same day, and perhaps to the same quan-
tity as before.

Sometimes the second bleeding may be larger than
the first. There are persons who, by their constitution,
are ready to faint, even upon a small bleeding; and in
such persons this may prevent the drawing so much
blood at first as a pneumonic inflammation might re-
quire; but, as the same persons are frequently found to
bear after-bleedings better than the first, this allows the
second and subsequent bleedings to be larger, and to
such a quantity as the symptoms of the disease may
seem to demand.

363. It is according to the state of the symptoms,
that bleedings are to be repeated; and they will be more

264 PRACTICE OF PHYSIC.

effectual when practised in the course of the first three
days, than afterwards; but they are not to be omitted,
although four days of the disease may have already
elapsed. If the physician shall not have been called in
sooner; or if the bleedings practised during the first
days shall not have been large enough, or even although
these bleedings shall have procured some remission;
yet upon the recurrence of the urgent symptoms, the
bleeding should be repeated at any period of the dis-
ease, especially within the first fortnight; and even af-
terwards, if a tendency to suppuration be not evident,
or, if, after a seeming solution, the disease shall have
again returned.*

364. With respect to the quantity of blood which
ought, or which with safety may be taken away, no ge-
neral rules can be delivered, as it must be very differ-
ent, according to the state of the disease and constitu-
tion of the patient.

In an adult male of tolerable strength, a pound of
blood, avoirdupois, is a full bleeding. Any quantity
above twenty ounces, is a large, and any quantity be-
low twelve, a small bleeding. A quantity of from four
to five pounds, in the course of two or three days, is ge-
nerally as much as such patients will safely bear; but, if
the intervals between the bleedings and the whole of
the time during which the bleedings have been em-

* As long as the pain, cough, difficulty of breathing, and hardness of the
pulse remain, the physician may with safety continue to bleed, entirely re-
gardless of the period of the disease. In his repetitions of venesection, he
must be governed entirely by the effects produced. If circumstances call
for it, three times in twenty-four hours are quite admissible. In some cases
three pints of blood have been drawn in a day with evident advantage. Such
instances, however, do not very frequently occur.

To prevent syncope, let the patient lie in a horizontal posture ; or even
with his head lower than his body. Fainting sometimes occurs on the first
act of venesection, but at no subsequent repetition of it.

PRACTICE OF PHYSIC. 265

ployed have been long, the quantity taken upon the
whole may be greater.

S65. When a large quantity of blood has been al-
ready taken from the arm, and when it is doubtful if
more can with safety be drawn in that manner, some
blood may still be taken by cupping and scarifying.
Such a measure will be more particularly proper, when
the continuance or recurrence of pain, rather than the
difficulty of breathing, becomes the urgent symptom;
and then the cupping and scarifying should be made as
near to the pained part as can conveniently be done.

366. An expectoration takes place sometimes very
early in this disease; but if, notwithstanding that, the
urgent symptoms should still continue, the expectora-
tion must not supersede the bleedings mentioned; and
during the first days of the disease, its solution is not to
be trusted to the expectoration alone. It is in a more
advauced stage only, when the proper remedies have
been before employed, and when the symptoms have
suffered a considerable remission, that the entire cure
may be trusted to a copious and free expectoration.*

367. During the first days of the disease, I have not
found that bleeding stops expectoration. On the con-
trary, I have often observed bleeding promote it; and it
is in a more advanced stage of the disease only, when
the patient, by large evacuations and the continuance of
the disease, has been already exhausted, that bleeding
seems to stop expectoration. It appears to me, that
even then bleeding does not stop expectoration, so much
by weakening the powers of expectoration, as by fa-
vouring the serous effusion into the bronchia?, (348)
and thereby preventing it.

* Our author's sentiments, as expressed in this and the next paragraph,
respecting blood-letting and expectoration, are correct. The former does
not injuriously check the latter, but often promotes it.
VOL. I. j, J

2Q6 PRACTICE OF PHYSIC.

368. While the bleedings we have mentioned shall
be employed, it will be necessary to employ also every
part of the antiphlogistic regimen, (130 — 132) and par-
ticularly to prevent the irritation which might arise
from any increase of heat. For this purpose, it will be
proper to keep the patient out of bed, while he can
bear it easily ; and when he cannot, to cover him very
lightly while he lies in bed. The temperature of his
chamber ought not to exceed sixty degrees of Faren-
heit's thermometer; and whether it may be at any time
colder, I am uncertain.*

369. Mild and diluent drinks, moderately tepid, at
least never cold, given by small portions at a time,
ought to be administered plentifully. These drinks
may be impregnated with vegetable acids. They may
be properly accompanied also with nitre, or some other
neutrals; but these salts should be given separately from
the drinks.

It has been alleged, that both acids and nitre are
ready to excite coughing, and in some persons they cer-
tainly have this effect; but except in persons of a pecu-
liar habit, I have not found their effects in exciting
cough so considerable or troublesome as to prevent our
seeking the advantages otherwise to be obtained from
these medicines.f

370. Some practitioners have doubted, if purgatives
can be safely employed in this disease; and indeed a
spontaneous diarrhoea occurring in the beginning of
the disease has seldom proved useful: but I have found
the moderate use of cooling laxatives generally safe,

* The patient ought not to be "kept out of bed," but may be lightly co-
vered in it. He should be kept where he will be most at his ease ; which
is certainly in bed.

f Barley water, flaxseed tea, bran tea, toast and water, or lemonade, are
suitable drinks: so is a mixture of molasses or currant jelly in water. These
may be taken, in general, ad libitum.

PRACTICE OF PHYSIC. 267

and have always found it useful to keep the belly open
by frequent emollient glysters.

371. To excite full vomiting by emetics, I judge to
be a dangerous practice in this disease: but I have
found it useful to exhibit nauseating doses; and in a
somewhat advanced state of the disease, I have found
such doses prove the best means of promoting expecto-
ration.*

372. Fomentations and poultices applied to the pain-
ed part have been recommended, and may be useful;
but the application of them is often inconvenient, and
may be entirely omitted for the sake of the more effec-
tual remedy, blistering.

Very early in the disease, a blister should be applied
as near to the pained part as possible. But as, when
the irritation of a blister is present, it renders bleeding
less effectual, so the application of the blister should be
delayed till a bleeding shall have been employed. If
the disease be moderate, the blister may be applied im-
mediately after the first bleeding; but if the disease be
violent, and it is presumed that a second bleeding may
be necessary soon after the first, it will then be proper
to delay the Blister till after the second bleeding, when
it may be supposed that any further bleeding may be
postponed till the irritation arising from the blister shall
have ceased. It may be frequently necessary in this

* As a nauseating medicine, and, at the same time, to produce a diapho-
resis, administer every hour, or oftener, the sixth of a grain of tartarized
antimony, combined with ten or twelve grains of nitre. This constitutes
also an excellent expectorant.

Although copious purging is not requisite, nor, perhaps, proper, in pe-
ripneumony, yet the bowels should be kept perfectly free from irritating
fxces. This purpose may be answered by injections and gentle laxatives.

Our author erroneously represents peripneumotvy as a disease confined
to an advanced period of life. Some of the severest attacks we have ever
witnessed have been in young persons — a few of them even under the age
of puberty.

268 PRACTICE OF PHYSIC.

disease to repeat the blistering: and in that case the
plasters should always be applied somewhere on the
thorax, for, when applied to more distant parts, they
have little effect. The keeping the blistered parts open,
and making what is called a perpetual blister, has much
less effect than a fresh blistering*

373. As this disease often terminates by an expecto-
ration, so various means of promoting this have been
proposed: but none of them appear to be very effectual;
and some of them being acrid stimulant substances,
cannot be very safe.

The gums usually employed seem too heating: squills
seem to be less so; but they are not very powerful, and
sometimes inconvenient by the constant nausea they
induce.

The volatile alkali may be of service as an expecto-
rant; but it should be reserved for an advanced state of
the, disease.

Mucilaginous and oily demulcents appear to be useful,
by allaying that acrimony of the mucus which occasions
too frequent coughing; and which coughing prevents
the stagnation and thickening of the mucus, and thereby
its becoming mild.

The receiving into the lungs the steams of warm water
impregnated with vinegar, has often proved useful in
promoting expectoration.

But, of all other remedies the most powerful for this
purpose, are antimonial medicines, given in nauseating
doses, as in (179). Of these, however, I have not found
the kermes mineral more efficacious than emetic tartar,

* It is worse than useless — it is injurious, to apply blisters in peripneu-
mony, before the pulse has been considerably reduced by means of blood-
letting. But when, by the previous treatment, the febrile action has been
sufficiently weakened, blistering becomes an invaluable remedy. The
plaster should be applied as near as possible to the part affected, and the
blister kept open until the pain be removed.

PRACTICE OF PHYSIC. 269

or antimonial wine; and the dose of the kermes is much
more uncertain than that of the others.*

374. Though a spontaneous sweating often proves
the crisis of this disease, it ought not to be excited by
art, unless with much caution. At least I have not
found it either so effectual or safe as some writers have
alleged. When, after some remission of the symptoms,
spontaneous sweats of a proper kind arise, they may be
encouraged; but it ought to be without much heat, and
without stimulant medicines. If, however, the sweats
be partial and clammy only, and a great difficulty of
breathing still remain, it will be very dangerous to en-
courage them.

375. Physicians have differed much in opinion with
regard to the use of opiates in pneumonic inflammation.
To me it appears, that, in the beginning of the disease,
and before bleeding and blistering have produced some
remission of the pain and of the difficulty of breathing,
opiates have a very bad effect, by their increasing the
difficulty of breathing, and other inflammatory symp-
toms. But in a more advanced state of the disease,
when the difficulty of breathing has abated, and when
the urgent symptom is a cough, proving the chief cause
of the continuance of the pain and of the want of sleep,
opiates may be employed with great advantage and safe-
ty. The interruption of the expectoration, which they
seem to occasion, is for a short time only: and they

* As an expectorant, the decoction of Seneka may be usefully employed.
From the exhibition of squills, we have never derived much advantage in
this disease. Partly as an expectorant, and partly as a diaphoretic, an infu-
sion of the Virginia snake-root may be administered with good effect.

Mucilaginous demulcents are useful ; but oily ones injurious. The latter
produce too much excitement.

We place no reliance on the inhalation of steams of any description. If
our patient be weak, the practice is inconvenient; and if not, other things
may be resorted to that are more advantageous. The best medium that can
be respired, is atmospheric air free from impurities.

270 PRACTICE OF PHYSIC.

seem often to promote it, as they occasion a stagnation
of what was by frequent coughing dissipated insensibly,
and therefore give the appearance of what physicians
have called Concocted Matter.*

CHAPTER VII.

OF THE PERIPNEUMONIA NOTHA, OR BASTARD
PERIPNEUMONY.f

376. A DISEASE under this name is mentioned in
some medical writings of the sixteenth century; but it

* Opiates should not be administered in this disease, until the symptoms
of pyrexia are greatly weakened. To allay pulmonary irritation, and pro-
cure rest, they then become an invaluable remedy. We think them most
effectual, when combined with the mucilage of gum arabic.

In protracted cases of peripneumony, the cure may be accelerated, and,
at the same time, rendered more certain and complete, by gently touching
the mouth with mercury. To effect this, a grain of calomel may be added
to each of the nitro-antimonial powders ; and, if requisite, a few drops of
laudanum given occasionally, to prevent them from purging.

In the treatment of peripneumony, it is of the utmost importance that the
disease be completely and radically cured. If any remnant of the cough be
left, it facilitates a relapse, or endangers, perhaps, consumption. This symp-
tom is most certainly removed, by carrying blood-letting to the proper ex-
tent. For that remedy nothing else can serve as a substitute.

f Our author's description of this disease is excellent ; and to what he has
said respecting the treatment of it, we have but little to add. We are con-
vinced that, in many cases, we believe, generally, blood-letting may be car-
ried further than he is willing to admit. In relation to this remedy, how-
ever, the state of the pulse and other symptoms, which it belongs to the
practitioner to examine for himself, must always govern. In a few instances
we have advantageously repeated blood-letting several times. The appear-
ance of the blood, and the effect produced by drawing it, can seldom fail to
give correct information as to the propriety of repeatirfg the operation.

We are of opinion, that a principal reason why such cautions are usually
enjoined, with regard to blood-letting in peripneumonia notha is, because it
is a disease of elderly persons. But that circumstance furnishes no solid
ground of objection against a liberal use of the remedy. In many instances,

PRACTICE OF PHYSIC. 21 1

is very doubtful if the name was then applied to the
same disease to which we now apply it. It appears to
me, that unless some of the cases described under the
title of Catarrhus Suffocativus be supposed to have been
of the kind I am now to treat of, there was no descrip-
tion of this disease given before that by Sydenham, un-
der the title I have employed here.

377. After Sydenham, Boerhaave was the first who
in a system took notice of it as a distinct disease; and
he has described it in his aphorisms, although with
some circumstances different from those in the descrip-
tion of Sydenham. Of late, Mr. Lieutaud has with great
confidence asserted, that Sydenham and Boerhaave had,
under the same title, described different diseases; and
that, perhaps, neither of them had on this subject deli-
vered any thing but the hypothesis.

the diseases of such persons are known to call for blood-letting to a great
extent.

Peripneumonia notha being, in fact, a kind of apoplexy of the lungs, we
do not perceive how it can be effectually treated without the free use of
the lancet.

We have been told, that much relief, and even permanent advantage,
have been derived in this disease, from breathing the fumes of rosin, and the
steams of warm water. Of these remedies, however, we have had no ex-
perience.

Although we would not hesitate to repeat " full vomiting" several times
in this disease, if called for by a continuance of unfavourable symptoms, we
think that circumspection is necessary, as to repeating it very "frequentli/."
It sometimes debilitates more than blood-letting.

As an expectorant in peripneumonia notha, the decoction of seneka has
been advantageously employed. So has syrup of squills.

Ulistcring and sweating are cardinal remedies in it. No expedient should
be omitted that is in any measure calculated to determine to the surface.
Small doses of ipecacuanha, repeatedly exhibited, are highly useful.

When, notwithstanding every effort to break its force, the disease conti-
nues obstinate, and great weakness begins to ensue, recourse must be had to
stimulants and cordials. Of these, wine whey, musk, and volatile alkali, may
be mentioned as among the most efficacious. They must be given in libe-
ral and repeated doses.

The ventilation of the patient's chamber .should be free ; but cold air
must be cautiously excluded.

212 PRACTICE OF PHYSIC.

378. Notwithstanding this bold assertion, I am hum-
bly of opinion, and the Baron Van Swieten seems to
have been of the same, that Sydenham and Boerhaave
did describe, under the same title, one and the same
disease. Nay, I am further of opinion, that the dis-
ease described by Mr. Lieutaud himself, is not essen-
tially different from that described by both the other
authors. Nor will the doubts of the very learned, but
modest Morgagni, on this subject, disturb us, if we con-
sider, that while very few describers of diseases either
have it in their power, or have been sufficiently attentive
in distinguishing between the essential and accidental
symptoms of disease; so, in a disease which may have
not only different, but a greater number of symptoms,
in one person than it has in another, we need not won-
der that the descriptions of the same disease by differ-
ent persons should come out in some respects different.
I shall, however, enter no further into this controversy;
but endeavour to describe the disease as it has appeared
to myself: and, as I judge, in the essential symptoms,
much the same as it has appeared to all the other au-
thors mentioned.

379. This disease appears at the same seasons that
other pneumonic and catarrhal affections commonly do;
that is, in autumn and spring. Like these diseases also,
it is seemingly occasioned by sudden changes of the
weather from heat to cold. It appears, also, during the
prevalence of contagious catarrhs; and it is frequently
under the form of the Peripneumonia Notha that these
catarrhs prove fatal to elderly persons.

This disease attacks most commonly persons some-
what advanced in life, especially those of a full phleg-
matic habit; those who have before been frequently lia-
ble to catarrhal affections; and those who have been

PRACTICE OF PHYSIC. 273

much addicted to the large use of fermented and spi-
rituous liquors.

The disease commonly comes on with the same symp-
toms as other febrile diseases; that is, with alternate
chills and heats; and the symptoms of pyrexia are some-
times sufficiently evident; but in most cases these are
very moderate, and in some hardly at all appear. With
the first attack of the disease, a cough comes on; usu-
ally accompanied with some expectoration, and in many
cases, there is a frequent throwing up of a considerable
quantity of viscid opaque mucus. The cough often be-
comes frequent and violent; is sometimes accompanied
with a rending headach; and, as in other cases of cough,
a vomiting is sometimes excited by it. The face is
sometimes flushed, and some giddiness or drowsiness
often attends the disease. A difficulty of breathing, with
a sense of oppression, or straitening in the chest, with
some obscure pains there, and a sense of lassitude over
the whole body, very constantly attend this disease. The
blood drawn in this disease, shows a buffy surface, as in
other inflammatory affections.

The disease has often the appearance only of a more
violent catarrh, and after the employmeMt of some reme-
dies, is entirely relieved by a free a»d copious expecto-
ration. In other cases, however the feverish and ca-
tarrhal symptoms are at fir^ very moderate, and even
slight; but after a few <&ys these symptoms suddenly
become considerable, and put an end to the patient's
life when the indications of danger were before very
little evident.

380. From the different circumstances in which this
disease appears, the pathology of it is difficult. It is
certainly often no other at first than a catarrhal affection,
which, in elderly persons, is frequently attended with a
large afflux of mucus to the lungs; and it was on this

vol. i. Mm

274 PRACTICE OF PHYSIC.

footing that Sydenham considered it as only differing
in degree from his Febris Hyemalis. A catarrh, how-
ever, is strictly an affection of the mucus membrane and
follicles of the bronchias alone: but it may readily have,
and frequently has, a degree of pneumonic inflamma-
tion joined to it; and in that case may prove more pro-
perly the peculiar disease we treat of here. But further,
as pneumonic inflammation very often produces an effu-
sion of serum into the bronchiae, (348.) so this, in elderly
persons, may oGcur in consequence of a slight degree
of inflammation; and when it does happen, will give ex-
quisite and fatal cases of the peripneumonia notha.

381. After this attempt to establish the pathology, the
method of cure in the different circumstances of the
disease will not be difficult.

In case the fever, catarrhal and pneumonic symptoms,
are immediately considerable, a blood-letting will cer-
tainly be proper and necessary: but, where these symp-
toms are moderate, a blood-letting will hardly be requi-
site; and when an effusion is to be feared, the repetition
of blood-Mting may prove extremely hurtful.

In all cast*, the remedies chiefly to be depended upon
are vomiting ai^i blistering.

Full vomiting n*y be frequently repeated, and nau-
seating doses ought to be constantly employed.

Purging may perhaps \i e useful; but as it is seldom
so in pneumonic affections, nothing but gentle laxatives
are here necessary.

In all the circumstances of this disease, the antiphlo-
gistic regimen is proper; cold is to be guarded against;
but much external heat is to be as carefully avoided.

382. If a person sweats easily, and it can be brought
out by the use of mild tepid liquors only, thf practice
may in such persons be tried. See Morgagni de Sed.
et Caus. Epist. xiii. Art. 4.

PRACTICE OF PHYSIC. 215

383. 1 might here, perhaps, give a separate section on
the Carditis and Pericarditis, or the inflammations of the
Heart and Pericardium; but they hardly require a par-
ticular consideration. An acute inflammation of the pe-
ricardium is almost always a part of the same pneumo-
nic affection I have been treating of; and is not always
distinguished by any different symptoms: or, if it be,
does not require any different treatment. The same may
be said of an acute inflammation of the heart itself; and
when it happens that the one or the other is discovered
by the symptoms of palpitation or syncope, no more
will be implied than that the remedies of pneumonic
inflammation should be employed with greater diligence.

From dissections, which show the heart and pericar-
dium affected with erosions, ulcerations, and abscesses,
we discover, that these parts had been before affected
with inflammation ; and that in cases where no symptoms
of pneumonic inflammation had appeared: it may there-
fore be alleged, that those inflammations of the heart
and pericardium should be considered as diseases inde-
pendent of the pneumonic. This indeed is just; but
the history of such cases proves that those inflamma-
tions had been of a chronic kind, and hardly discovering
themselves by any peculiar symptoms; or if attended
with symptoms marking an affection of the heart, these
were however such as have been known frequently to
arise from other causes than inflammation. There is,
therefore, upon the whole, no room for our treating
more particularly of the inflammation of the heart or
pericardium.

276 PRACTICE OF PHYSIC.

CHAPTER VIII.

OF THE GASTRITIS, OR INFLAMMATION OF THE
STOMACH.*

384. AMONG the inflammations of the abdominal re-
gion, I have given a place in our Nosology to the Peri-
tonitis; comprehending under that title, not only the
inflammations affecting the peritonaeum lining the ca-

* Our experience in gastritis, strictly so called, has been but limited.
The cases we have seen have arisen from the drinking 1 of cold water, from
mechanical injuries, or from the intemperate use of ardent spirits, one from
coirosive sublimate, swallowed by mistake, and another from an excessive
dose of the spirits of turpentine. In all of them the symptoms have been
the same — pyrexia, with a small, but frequent, quick, hard, and corded
pulse, a sensation of agony in the epigastric region, soreness to the touch,
a perceptible degree of tension, such a morbid irritability of stomach as led
to the rejection of every thing that was swallowed, and a prostration of
strength greater than we have witnessed in any other of the Phlegmasia:.
This prostration manifests conclusively the powerful sympathies that exist
between the stomach and the other parts of the system.

The practice pursued in these cases was, blood-letting to a considerable
extent — not in large quantities at once, but frequently repeated, blistering
very extensively on the region of the part affected, and purging by means
of active injections. By the mouth nothing was exhibited but drinks, and
those very sparingly. The liquids that answered best for this purpose were,
simple water, a very thin mucilage of gum arabic, two-milk whey, and sweet
milk, diluted with about twice its quantity of water. Although these arti-
cles were frequently rejected, they occasioned less distress, and were
longer and more generally retained than any thing else.

Anodyne injections gave a considerable respite from suffering, and pro-
cured for the sick some rest during the night, without adding to the py-
rexia, or being productive, in any respect, of injurious effects. They were,
therefore, considered as an important remedy -. for, when labouring under
gastritis, sleep is the only restorative the unfortunate patient is permitted
to enjoy. Each injection was composed of three grains of opium, dissolved
in a small quantity of water, and mixed with a gill of the mucilage of gum
arabic.

In this complaint it is of the utmost moment to keep up the peristaltic
motion of the bowels, as it carries off from the stomach such secreted and
other matters, as might prove offensive and injurious irritants. It operates
somewhat like a topical evacuation, reducing the inflammatory excitement
of the part.

PRACTICE OF PHYSIC. 277

vity of the abdomen, but also those affecting the exten-
sions of this membrane in the omentum and mesentery.
It is not, however, proposed to treat of them here, be-
cause it is very difficult to say by what symptoms they
are always to be known; and farther, because when
known, they do not require any remedies beside those
of inflammation in general. I proceed, therefore, to
treat of those inflammations, which, affecting viscera of
peculiar functions, both give occasion to peculiar symp-
toms, and require some peculiarities in the method of
cure; and I shall begin with the inflammation of the
stomach.

385. The inflammation of the stomach is of two
kinds, Phlegmonic, or Erythematic* The first may
be seated in what is called the Nervous Coat of the
stomach, or in the peritonaeum investing it. The se-
cond is always seated in the villous coat and cellular
texture immediately subjacent.

386. The phlegmonic inflammation of the stomach,
or what has been commonly treated of under the title
of Gastritis, is known by an acute pain in some part of
the region of the stomach, attended with pyrexia, with
frequent vomiting, especially upon occasion of any thing
being taken down into the stomach, and frequently with
hickup. The pulse is commonly small and hard; and
thsre is a greater loss of strength in all the functions of
the body, than in the case of almost any other inflam-
mation.

387. This inflammation may be produced by various
causes; as, by external contusion; by acrids of various
kinds taken into the stomach; frequently by very cold
drink taken into it while the body is very warm; and

* This is a new term; but whoever considers what is said in 274. will,
I expect, perceive the propriety, and even the necessity of it.

Cullex.

278 PRACTICE OF PHYSIC.

sometimes by over-distention, from the having taken in
a large quantity of food of difficult digestion. All these
may be considered as external causes; but the disease
sometimes arises also from internal causes not so well
understood. It may arise from inflammations of the
neighbouring parts communicated to the stomach, and
is then to be considered as a symptomatic affection only.
It may arise also from various acrimonies generated
within the body, either in the stomach itself, or in other
parts, and poured into the cavity of the stomach. These
are causes more directly applied to the stomach; but
there are perhaps others originating elsewhere, and af-
fecting the stomach only sympathetically. Such may be
supposed to have acted in the case of putrid fevers and
exanthematic pyrexia; in which, upon dissection, it has
been discovered that the stomach had been affected
with inflammation.*

388. From the sensibility of the stomach, and its
communication with the rest of the stystem, it will be
obvious, that the inflammation of this organ, by what-
ever causes produced, may be attended with fatal con-
sequences. In particular, by the great debility which
such an inflammation suddenly produces, it may quickly
prove fatal without running the common course of in-
flammations.

When it lasts long enough to follow the ordinary
course of other inflammations, it may terminate by re-

* The inflammation which appears in the stomach in malignant, or, what
our author calls " putrid fevers, and exanthematic pyrexia," shows clearly,
.is we have heretofore stated, that those diseases have their primary seat in
that organ. It is produced, not by any " acrimonies generated in the body,
and poured into the cavity of the stomach," but by the original poisons of
those disejses making their way into that organ, and perpetrating on it lo-
cally thei'rSideleterious effects.

If the disease arise from the action of any poison that can be easily neu-
tralized, and which has not yet been evacuated, — an acid or an alkali, for ex-
ample — let its opposite, or neutralize^ be immediately thrown into the sto-
mach.

PRACTICE OF PHYSIC. 279

solution, gangrene, or suppuration. The scirrhosities
which are often discovered affecting the stomach, are
seldom known to be the consequences of inflammation.

389. The tendency of this disease to admit of resolu-
tion, may be known, by its having arisen from no vio-
lent cause; by the moderate state of the symptoms; and
by a gradual remission of these, especially in conse-
quence of remedies employed in course of the first, or
at farthest, the second week of the disease.

390. The tendency to suppuration may be known by
the symptoms continuing, in a moderate degree, for
more than one or two weeks; and likewise by a consi-
derable remission of the pain, while a sense of weight
and an anxiety still remain.

When an abscess has been formed, the frequency of
the pulse is at first abated; but soon after, it is again
increased, with frequent cold shiverings, and with mark-
ed exacerbations in the afternoon and evening, followed
by night sweatings, and other symptoms of hectic fever.
These at length prove fatal, unless the abscess open into
the cavity of the stomach, the pus be evacuated by vo-
miting, and the ulcer soon heal.

391. The tendency to gangrene may be suspected
from the violence of the symptoms not yielding to the
remedies employed during the first days of the disease:
and that a gangrene has already begun, may be known
from the sudden remission of the pain, while the fre-
quency of the pulse continues, and at the same time be-
comes weaker, accompanied with other marks of an in-
creasing debility in the whole system.

392. From the dissection of dead bodies it appears,
that the stomach very often has been affected Vfith in-
flammation, when the characteristic symptoms of it
(386,) had not appeared; and therefore it is very diffi-

280 PRACTICE OF PHYSIC.

cult to lay down any general rules for the cure of this
disease.

393. It is only in the case of phlegmonic inflamma-
tion, as characterized in 386., that we can advise the
cure or resolution to be attempted by large and repeated
bleedings employed early in the disease: and we are not
to be deterred from these by the smallness of the pulse;
for after bleeding it commonly becomes fuller and softer.
After bleeding, a blister ought to be applied to the re-
gion of the stomach; and the cure will be assisted by
fomentations of the whole abdomen, as well as by fre-
quent emollient and laxative glysters.

394. In this disease, the irritability of the stomach
will not admit of any medicines being thrown into it;
and if any internal medicines can be supposed neces-
sary, they must be exhibited in glysters. The giving of
drink may be tried; but it ought to be of the very mild-
est kind, and in very small quantities at a time.

395. Opiates, in whatever manner exhibited, are very
hurtful during the first days of the disease; but when its
violence shall have abated, and when the violence of the
pain and vomiting recur at intervals only, opiates given
in glysters may be cautiously tried, and sometimes have
been employed with advantage.

396. A tendency to suppuration, in this disease, is to
be obviated by the means just now proposed. After a
certain duration of the disease, it cannot be prevented
by any means whatever; and when actually begun must
be left to nature; the business of the physician being
only to avoid all irritation.

397. A tendency to gangrene can be obviated in no
other way than by the means suggested, (393.) employed
early in the disease; and, when it does actually super-
vene, admits of no remedy.

PRACTICE OF PHYSIC. 281

398. Erythematic inflammations of the stomach, are
more frequent than those of the phlegmonic kind. It
appears at least, from dissections, that the stomach has
often been affected with inflammation, when neither
pain nor pyrexia had before given any notice of it; and
such inflammation 1 apprehend to have been chiefly of
the erythematic kind. This species of inflammation also
is especially to be expected from acrimony of any kind
thrown into the stomach; and would certainly occur
more frequently from such a cause, were not the inte-
rior surface of this organ commonly defended by mucous
exuding in large quantities from the numerous follicles
placed immediately under the villous coat. Upon many
occasions, however, the exudation of mucus is prevent-
ed, or the liquid poured out is of a less viscid kind, so
as to be less fitted to defend the subjacent nerves; and
it is in such cases that matters, even of moderate acri-
mony, may produce an erythematic affection of the
stomach.

399. From what has been said, it must appear that an
erythematic inflammation of the stomach may frequently
occur; but will not always discover itself, as it some-
times takes place without pyrexia, pain, or vomiting.

400. There are cases, however, in which it may be
discovered. The affection of the stomach sometimes
spreads into the oesophagus, and appears in the pharynx,
as well as on the whole internal surface of the mouth.
When, therefore, an erythematic inflammation affects
the mouth and fauces, and when at the same time there
shall be in the stomach an unusual sensibility to all
acrids, with a frequent vomiting, there can be little
doubt of the stomach being affected with the same in-
flammation that has appeared in the fauces. Even when
no inflammation appears in the fauces, yet if some degree
of pain be felt in the stomach, if there be a want of

vol. i. n n

,282 PRACTICE OF PHYSIC

appetite, an anxiety, frequent vomiting, an unusual sen-
sibility, with respect to acrids, some thirst, and frequency
of pulse, there will then be room to suspect an erythe-
matic inflammation of the stomach; and we have known
such symptoms, after some time, discover their cause
more clearly, by the appearance of the inflammation in
the fauces or mouth. Erythematic inflammation is often
disposed to spread from one place to another on the
same surface; and, in doing so, to leave the place it had
at first occupied. Thus, such an inflammation has been
known to spread successively along the whole course of
the alimentary canal, occasioning in the intestines diar-
rhoea, and in the stomach vomitings; the diarrhcea ceasing
when the vomiting came on, or the vomitings upon the
coming on of the diarrhoea.

401. When an erythematic inflammation of the sto-
mach shall be discovered, it is to be treated differently,
according to the difference of its causes and symptoms.

When it is owing to acrid matters taken in by the
mouth, and when these may be supposed still present
in the stomach, they are to be washed out by throwing
in a large quantity of warm and mild liquids, and by
exciting vomiting. At the same time, if the nature of
the acrimony and its proper corrector be known, this
should be thrown in; or if a specific corrector be not
known, some general demulcents should be employed.

402. These measures, however, are more suited to
prevent the inflammation, than to cure it after it has
taken place. When this last may be supposed to be the
case, if it be attended with a sense of heat, with pain
and pyrexia, according to the degree of these symptoms,
the measures proposed in 393. are to be more or less
employed.

403. When an erythematic inflammation of the sto-
mach has arisen from internal causes, if pain and

PRACTICE OF PHYSIC. 283

pyrexia accompany the disease, some bleeding in per-
sons not otherwise weakened, may be employed; but,
as the affection often arises in putrid diseases, and in
convalescents from fever; so in these cases, bleeding is
inadmissible; all that can be done being to avoid irrita-
tion, and to throw into the stomach what quantity of
acids, and of acescent aliments, it shall be found to bear.
In some conditions of the body, in which this disease
arises, the Peruvian bark and bitters may seem to be
indicated: but an erythematic state of the stomach does
not commonly allow of them.

CHAPTER IX.

OF THE ENTERITIS, OR INFLAMMATION OF THE
INTESTINES.*

404. THE inflammation of the intestines, like that of
the stomach, maybe either phlegmonic or erythematic;
but on the subject of the latter, I have nothing to add

* As far as we may rely on our own experience, we think that the prin-
cipal difference between the treatment of this and the preceding disease is,
that here there is somewhat more room to operate on the stomach, and
blood-letting may be carried to a greater extent.

In the first stages of enteritis, however, it is unsafe to throw purgative
medicines into the stomach, in as much as they are likely to be either re-
jected, or to remain and fail of their effect ; in either of which cases their
irritation does mischief. The bowels must be moved, therefore, by means
of injections ; and it is important that they be frequently and effectually
cleared of their irritating contents. Injections of cold water, besides being
grateful and refreshing to the patient, are usually productive of a purgative
effect They are, perhaps, therefore, on the whole, the most useful that
can be employed; particularly if they be quickened in their action by an
addition of Epsom or Glauber's salts.

Should these, however, fail in opening the bowels, the antimonial in-
jection will probably succeed. This consists of twenty grains of tartarized
antimony dissolved in a pint of water, or an equal quantity of the mucilage of
gum arabic. If carefully thrown into the rectum, it rarely fails in procuring
a speedy and copious evacuation.

£84 PRACTICE OF PHYSIC. '

to what has been said in the last chapter; and shall here,
therefore, treat of the phlegmonk inflammation only.

405. This inflammation may be known to be present,
by a fixed pain of the abdomen, attended with pyrexia,
costivenessand vomiting. Practical writers mention the
pain in this case as felt in different parts of the abdomen,
according to the different seat of the inflammation; and
so, indeed, it sometimes happens; but very often the pain
spreads over the whole belly, and is felt more especially
about the navel

406. The Enteritis and Gastritis arise from like causes;
but the former, more readily than the latter, proceeds
from cold applied to the lower extremities,, or to the
belly itself. The enteritis has likewise its own peculiar
causes, as supervening upon the spasmodic colic, in-
carcerated hernia, and volvulus.

407. Inflammations of the intestines have the same
terminations as those of the stomach; and, in both cases,
the several tendencies are to be discovered by the same
symptoms (389. 391).

408. The cure of the enteritis is, in general, the same
with that of the gastritis; (393. et seq.): but in the ente-
ritis there is commonly more access to the introduction
of liquids, of acid, acescent, and other cooling remedies,
and even of laxatives. As, however, a vomiting so fre-
quently attends this disease, care must be taken not to
excite that vomitingrby either the quantity or the qua-
lity of any thing thrown into the stomach.

The same observation with respect to the use of opi-
ates is to be made here as in the case of gastritis.

When the bowels have been thoroughly emptied, the anodyne injection
may be used here with nearly the same advantage as in inflammation of the
stomach

But it is unnecessary to dwell any longer on this complaint. The physi-
cian who understands the treatment of gastritis, cannot fail in that of en-
teritis.

PRACTICE OF PHYSIC. 285

409. Under the title of Enteritis, it has been usual
with practical writers to treat of the remedies proper for
the colic, and its higher degree named Ileus: but, al-
though it be true that the enteritis and colic do fre-
quently accompany each other, I still hold them to be
distinct diseases, to be often occurring separately, and
accordingly to require and admit of different remedies. I
shall therefore delay speaking of the remedies proper
for the colic, till I shall come to treat of this disease in
its proper place.

410. What might be mentioned with respect to the
suppuration or gangrene occurring in the enteritis, may
be sufficiently understood from what has been said on
the same subject with respect to the gastritis.

CHAPTER X.

OF THE HEPATITIS, OR INFLAMMATION OF THE
LIVER.*

411. THE inflammation of the liver seems to be of
two kinds: the one acute, the other chronic.

412. The acute is attended'with pungent pain; consi-

* Although the contents of this chapter cannot be denied to be correct
and judicious, as far as they go, we find no ground to conclude from them,
that Dr. Cullen had ever much experience in inflammations of the liver.
We are almost compelled, on the other hand, to believe the reverse.

The doubts which the professor expresses, and the want of knowledge
he manifests, on the subject of chronic hepatitis, are to be attributed, we
presume, to his having always lived and practised in a healthy country,
where that form of disease but rarely made its appearance. Here, and in
warm climates, the complaint is almost as well known and as easily distin-
guished, as small pox or measles, cholera morbus or intermitting fever.

In acute hepatitis, properly so called, the symptoms of which our author
has very accurately enumerated, the mode of treatment differ sin no material
point from that which we pursue in other violent cases of phlegmasia. As
the disease is obstinate and unusually rapid in its progress towards sup-

286 PRACTICE OF PHYSIC.

derable pyrexia; a frequent, strong, and hard pulse; and
high coloured urine.

413. The chronic hepatitis very often does not exhi-

puration, it calls for practice of great energy. Blood-letting, in particular,
must be carried, in a given time, to an extent not common, and scarcely
warranted in other complaints. From a robust and vigorous subject, we
have known nearly four pounds of blood to be taken in a day, not
onlv with safety, but evident advantage. We have reason to believe that
a smaller quantity would have been altogether below the exigency of the
disease. While the pulse remains full and strong, and the pain in the side
pungent, blood-letting is the only remedy on which we can rely. In the
mean time, however, it should be aided by copious purging with calomel,
quickened in its action by jalap and a strong infusion of senna. The infusion
of senna, with nearly as much of Glauber's or Epsom salts as it will hold in
solution, constitutes also an excellent purge.

While these operations are going forward, cups or leeches, or both,
should be liberally applied to the region of the liver, and a large blister laid
on the same, as soon as the febrile action is sufficiently reduced But if
blistering be resorted to at too early a period, besides standing in the way
of topical blood-letting, it can scarcely fail on other grounds to be produc-
tive of mischief.

These remedies, connected with a rigid enforcement of the antiphlogistic
regimen, constitute our reliance in acute hepatitis. The minor aids deemed
necessary may be varied according to the judgment and experience of the
practitioner. After the inflammation has been sufficiently reduced, it will
be the safest practice, to remove the disease entirely by a gentle mercurial
ptyalism, to be continued for some time.

In chronic hepatitis venesection is also essential ; but must not be pushed
to the same extent in a given time. There exists, however, scarcely any
complaint in the course of which so large a quantity of blood has been taken
from the patient with advantage, as in some cases of that which we are now
considering. But, as the disease is chronic, such must be the remedies,
gradually, but firmly and perseveringly employed.

Here also the application of cups to the region of the liver is highly use-
ful : but the most important topical remedy is a perpetual blister ; or, what
is better still, a caustic or a seton. From the latter remedy, in particular, we
have derived effects unexpectedly salutary.

But in the treatment of chronic hepatitis, our chief reliance is on a gentle
but continued mercurial ptyalism. Should the system be likely to sink un-
der this remedy, let it be discontinued, for a time, and then recommenced ;
and let this plan be steadily pursued, until every symptom of the complaint
shall have disappeared.

If the season be mild, and the febrile action very moderate, the patient
maybe allowed to take gentle exercise in the open air. But no one, under
the influence of mercury, should ever venture out of his chamber in damp
or cold weather. It is to a neglect of this precaution that we are to attri-

PRACTICE OF PHYSIC. 287

bit any of these symptoms; and it is only discovered to
have happened, by our finding in the liver, upon dissec-
tion, large abscesses, which are presumed to be the ef-
fect of some degree of previous inflammation. As this
cnronic inflammation is seldom to be certainly known,
and therefore does not lead to any determined practice,
we omit treating of it here, and shall only treat of what
relates to the acute species of the hepatitis.

414. The acute hepatitis may be known by a pain
more or less acute in the right hypochondrium, increased
by pressing upon the part. The pain is very often in
such a part of the side as to make it appear like that of
a pleurisy; and frequently, like that too, is increased on
respiration. The disease is, in some instances, also at-
tended with a cough, which is commonly dry, but some'
times humid: and when the pain thus resembles that of
a pleurisy, the patient cannot lie easily except upon the
side affected.

bute the frequent failure of that remedy, and the many injurious effects
that occasionally result from the use of it. When exhibited under proper
circumstances, there is no remedy more perfectly safe than mercury; nor is
there any one more dangerous if used indiscreetly.

Another remedy, which lias acquired a high reputation in the treatment
of chronic hepatitis, is the nitric aeid. It may be given, in divided doses, to
the amount of from one to three or four drachms in twenty-four hours. A
pleasant formula is, to make it into a julep with mucilage of gum arabic,
mint, or lavender water, and loaf sugar.

In the use of this remedy, our experience is limited. It is recommended,
therefore, on the testimony of others, rather than on our own. personal
knowledge.

With some physicians of eminence, the expressed juice of the dande-
lion, taken in the quantity of from a gill to half a pint a day, is ia high
reputation.

When all other remedies have failed of a perfect cure, we have known
chronic hepatitis completely removed, by the long continued action of a se-
ton in the right hypochondriac region.

To success in this disease, under any plan of treatment, the use of flan-
nel next the skin, and an adherence to the antiphlogistic regimen, is ne-
cessary.

As a laxative and an alterative, the long continued use of pills, composed
of rhubarb and castile soap, is highly recommended.

288 PRACTICE OF PHYSIC.

In every kind of acute hepatitis, the pain is often ex-
tended to the clavicle, and to the top of the shoulder.
The disease is attended sometimes with hickup, and
sometimes with vomiting. Many practical writers have
mentioned the jaundice, or a yellow colour of the skin
and eyes, as a very constant symptom of the hepatitis;
but experience has shown, that it may often occur with-
out any such symptom.

415. The remote causes of hepatitis are not always to
be discerned, and many have been assigned on a very
uncertain foundation. The following .seem to be fre-
quently evident. 1. External violence from contusions
or falls, and especially those which have occasioned a
fracture of the cranium. 2. Certain passions of the mind.
3. Violent summer heats. 4. Violent exercise 5. Inter-
mittent and remittent fevers. 6. Cold applied externally,
or internally; and therefore in many cases the same
causes which produce pneumonic inflammation, pro-
duce hepatitis; and whence also the two diseases are
sometimes joined together. 7. Various solid concretions
or collections of liquid matter, in the substance of the
liver, produced by unknown causes. Lastly, the aeute
is often induced by a chronic inflammation of this
viscus.

416. It has been supposed, that the hepatitis may be
an affection either of the extremities of the hepatic ar-
tery, or of those of the vena portarum; but of the last
supposition there is neither evidence nor probability.

417. It seems probable, that the acute hepatitis is
always an affection of the external membrane of the
liver; and that the parenchymatic is of the chronic
kind. The acute disease may be seated either on the
convex or on the concave surface of the liver. In the
former case, a more pungent pain and hickup may be
produced, and the respiration is more considerably af-

PRACTICE OF PHYSIC. 289

fected. In the latter, there occurs less pain ; and a vo-
miting is produced, commonly by some inflammation
communicated to the stomach. The inflammation of
the concave surface of the liver, may be readily com-
municated to the gall-bladder and biliary ducts; and
this perhaps is the only case of idiopathic hepatitis at-
tended with jaundice.

418. The hepatitis, like other inflammations, may
end by resolution, suppuration, or gangrene; and the
tendency to the one or the other of these events, may
be known from what has been delivered above.

419. The resolution of hepatitis is often the conse-
quence of, or is attended with, evacuations of different
kinds. A hemorrhagy, sometimes from the right nos-
tril, and sometimes from the hemorrhoidal vessels, gives
a solution of the disease. Sometimes a bilious diar-
rhoea contributes to the same event; and the resolution
of the hepatitis, as of other inflammations, is attended
with sweating, and with an evacuation of urine, depo-
siting a copious sediment. Can this disease be resolv-
ed by expectoration? It would seem to be sometimes
cured by an erysipelas appearing in some external part.

420. When this disease has ended in suppuration,
the pus collected may be discharged by the biliary
ducts; or, if the suppurated part does not any where
adhere closely to the neighbouring parts, the pus may
be discharged into the cavity of the abdomen; but if,
during the first state of inflammation, the affected part
of the liver shall have formed a close adhesion to some
of the neighbouring parts, the discharge of the pus
after suppuration may be various, according to the dif-
ferent seat of the abscess. When seated on the con-
vex part of the liver, if the adhesion be to the perito-
naeum lining the common teguments, the pus may
make its way through these, and be discharged out-

VOL. I. oo

290 PRACTICE OF PHYSIC.

wardly ; or, if the adhesion should have been to the
diaphragm, the pus may penetrate through this, and into
the cavity of the thorax, or of the lungs, and through
the latter may be discharged by coughing. When the
abscess of the liver is seated on its concave part, then,
in consequence.of adhesions, the pus may be discharg-
ed into the stomach or the intestines; and into these
last, either directly, or by the intervention of the biliary
ducts.

421. The prognostics in this disease are established
upon the general principles relating to inflammation,
upon the particular circumstances of the liver, and
upon the particular state of its inflammation.

The cure of this disease must proceed upon the ge-
neral plan ; by bleeding, more or less, according to the
urgency of pain and pyrexia; by the application of
blisters; by fomentations, of the external parts in the
usual manner, and of the internal parts by frequent
emollient glysters; by frequently opening the belly, by
means of gentle laxatives, and by diluent and refrige-
rant remedies.

4>22. Although, in many cases, the chronic hepatitis
does not clearly discover itself; yet upon many occa-
sions it may perhaps be discovered, or at least suspect-
ed from those causes which might affect the liver (316.)
having been applied; from some fulness and some sense
of weight in the right hypochondrium; from some shoot-
ing pains at times felt in that region; from some unea-
siness or pain felt upon pressure in that part; from some
uneasiness from lying upon the left side; and lastly,
from some degree of pyrexia, combined with more or
fewer of these symptoms. When, from some of these
circumstances, a chronic inflammation is to be suspect-
ed, it is to be treated by the same remedies as in the

PRACTICE OF PHYSIC. ^91

last paragraph, employed more or less, as the degree
of the several symptoms shall more distinctly indicate.

423. When from either kind of inflammation, a sup-
puration of the liver has been formed, and the abscess
points outwardly, the part must be opened, the pus eva-
cuated, and the ulcer healed according to the ordinary
rules for cleansing and healing such abscesses and ulcers.

424. I might here consider the Splenitis, or inflam-
mation of the spleen; but it does not seem necessary,
because the disease very seldom occurs. When it does,
it may be readily known by the character given in our
Nosology: and its various termination, as well as the
practice which it requires, may be understood from what
has been already said with respect to the inflammations
of the other abdominal viscera.

CHAPTER XI.

OF THE NEPHRITIS, OR THE INFLAMMATION OF
THE KIDNEYS.

425. THIS disease, like other internal inflammations,
is always attended with pyrexia ; and is especially known
from the region of the kidney being affected with pain,
commonly obtuse, sometimes pungent. This pain is not
increased by the motion of the trunk of the body, so
much as a pain of the rheumatic kind affecting the same
region. The pain of the nephritis may be often dis-
tinguished by its shooting along the course of the ureter;
and is frequently attended with a drawing up of the
testicle, and with a numbness of the limb on the side
affected; although, indeed, these symptoms most com-
monly accompany the inflammation arising from a cal-
culus in the kidney, or in the ureter. The nephritis is

292 PRACTICE OF PHYSIC.

almost constantly attended with frequent vomiting, and
often with costiveness and colic pains. Usually the state
of the urine is changed; it is most commonly of a deep
red colour, is voided frequently, and in small quantity
at a time. In more violent cases the urine is sometimes
colourless.

426. The remote causes of this disease may be vari-
ous; as, external contusion; violent or long continued
riding: strains-of the muscles of the back incumbent on
the kidneys; various acrids in the course of the circula-
tion, conveyed to the kidneys; and perhaps some other
internal causes not yet well known. The most frequent
is that of calculous matter obstructing the tubuli, urini-
feri, or calculi formed in the pelvis of the kidneys, and
either sticking there, or fallen into the ureter. •

421. The various event of this disease may be under-
stood from what has been delivered on the subject of
other inflammatfons.

428. Writers, in treating of the cure of the nephritis,
have commonly at the same time treated of the cure of
the calculis renalis; but, though this may often produce
nephritis, it is to be considered as a distinct and sepa-
rate disease ; and what I have to offer as to the mode of
treating it, must be reserved to its proper place. Here I
shall treat only of the cure of the Mephritis Vera or
Idiopathica.

429. The cure of this proceeds upon the general
plan, by bleeding, external fomentation, frequent emol-
lient glysters, antiphlogistic purgatives, and the free
use of mild and demulcent liquids. The application of
blisters is hardly admissible; or, at least, will require
great care, to avoid any considerable absorption of the
cantharides.*

* In addition to venesection, recommended by our author, which must be
pushed, at times, to a considerable extent, copious topical blood-letting

PRACTICE OF PHYSIC. 293

430. The Cystitis, or inflammation of the bladder, is
seldom a primary disease; and therefore is not to be
treated of here. The treatment of it, so far as necessary

from the region of the kidneys, by cups or leeches, is an important remedy
in Nephritis, and should by no means be omitted. It may be repeated,
with advantage, should the continuance of fever, and the obstinacy and
severity of the pain require it.

The professor's fears, in relation to the absorption of cantharides in case
of blistering, are totally unfounded. Cantharides are not absorbed; and the
affection of the urinary organs, under these circumstances, is entirely sympa-
thetic. Besides, it is not in the kidneys, but in the bladder, that the irrita-
tion is produced. We do not, therefore, perceive how it can be injurious in
the treatment of Nephritis : nor have we, from experience, ever found it so.
On the other hand, we think blistering on the lumbar region, in this com-
plaint, not only an admissible but a useful remedy ; the more so, in as much
a^ the irritation produced on the neck of the bladder may lessen that in the
kidneys through the medium of sympathy. If the primary irritation, by a
blister on the skin, be useful in removing an internal topical affection, why
not the secondary one on the neck of the bladder? Whether our reasoning
on this head be, in all points, conclusive or not, we are persuaded that
blistering at the proper period of Nephritis is not hurtful. It is considered
so, not from observation, but on principles of hypothesis.

In addition to the plan of treatment, enjoined by our author, in this dis-
ease, viz. the antiphlogistic regimen generally, bleeding, purging by glys-
ters, and the copious use of demulcent drinks, we can recommend, from
experience, lying on a mattress instead of a feather bed, and the employ-
ment of mercury. The former of these prevents the accumulation of undue
warmth around the region of the kidneys, and the latter we have found to
be a most important remedy, when carried to the extent of a gentle saliva-
tion. To this we have known a nephritic affection immediately to give way,
after it had resisted every other remedy that is usually employed. As in
most other cases of disease, the preparation of mercury we have commonly
made use of is calomel, given to the amount of three or four grains per day.
Nor have we hesitated for a moment to add to each dose of calomel ten or
twelve grains of nitre : convinced that that neutral salt is not only safe but
useful. It acts primarily on the stomach, and by sympathy on the kidneys ;
and produces, as we feel persuaded, on these latter organs, no injurious
irritation by making its way into the serum of the blood.

Warm fomentations extensively applied on the lumbar region, seldom fail
to give relief in this disease. If practicable to employ them, therefore, they
should never be neglected. Great care, however, must be taken, lest, by
exposure to cold immediately afterwards, or at the time, the patient expe-
rience a chill.

As the sickness at stomach, which usually, or at least very often, accom-
panies this disease, reduces by sympathy the action of the arteries, without
actually relieving the existing inflammation, the pulse cannot be very confi-
dently relied on as an index to blood-letting. The appearance of the blood

294 PRACTICE OF PHYSIC.

to be explained, may be readily understood from what
has been already delivered.

431. Of the visceral inilammations there remains to
be considered the inflammation of the Uterus; but I
omit it here, because the consideration of it cannot be
separated from that of the diseases of child-bearing wo-
men.

already drawn, and the degree of pain that may still continue, must be care-
fully attended to in settling the indication.

Respecting the diseases of Cystitis and Hysteritis, which our author refers
to in this chapter, we think it necessary to observe, that, in their treatment,
they require blood-letting, for the most part to very great extent.

The reason of this we think sufficiently obvious. The bladder and ute-
rus, being detached organs, are supplied with blood by arteries of inferior
size. They cannot, therefore, feel the effect of each act of venesection in
the same degree as if their arteries were larger. To. bleed from the arm
in these complaints is somewhat as it would be to open the same vein in a
case of whitlow. The part inflamed is but little affected by it. It is hence
that the operation must be frequently repeated, until the action of the arte-
ries is very much reduced.

Could topical blood-letting be practised on the parts affected, it would
prove a much more efficacious remedy. Cups and leeches applied exter-
nally in the region of these parts, and also in the groins, are found to be
useful. The quantity of blood taken away by them ought to be copious.
But, for general blood-letting, although not so efficacious here as we could
wish it to be, nothing can operate as a substitute.

Puking is said to be a more useful remedy in these diseases, especially in
Hysteritis, than in any other of the phlegmasia. From the direct and pow-
erful sympathy that exists between the stomach and uterus, were are not
much inclined to a disbelief of the fact. Our own experience, however,
does not authorize us to decide on the subject. We consider the remedy
worth a trial.

In Hysteritis, and Cystitis in females, what would be the effect of the in-
troduction of ice, or the frequent injection of cold water into the vagina ?

In the treatment of cystitis in males, the application of ice to the peri-
neum and external organs of generation has been found useful. A copious
extraction of blood from the perineum by means of leeches, may be also
practised with advantage. Bleeding from the hemorrhoidal vessels is also
said to afford relief. These several remedies seem founded in reason.

PRACTICE OF PHYSIC. 295

CHAPTER XII.
OF THE RHEUMATISM.*

432. OF this disease there are two species, the one
named the Acute, the other the Chronic rheumatism.

* Our author's history and description of this disease, as well as his expo-
sition of the principles of practice in it, are ample and excellent. We know
but few pieces of medical composition richer in matter that is worth remem-
bering. On the attention of students of medicine, therefore, it has the
strongest of claims. It will instruct them in the knowledge of an important
disease.

The hereditary nature of Rheumatism constitutes a feature in the charac-
ter of that complaint, which we do not recollect to have seen any where re-
presented. Yet that it possesses such a feature, does not, we think, admit
of a doubt.

It is indeed true, that if exposed for a sufficient length of time to its excit-
ing causes, most persons will be ultimately attacked by rheumatism. But it is
no less true, that some of these will suffer from it much sooner, and more
readily and certainly, than others; not because they have weaker systems;
but because they are constitutionally predisposed to the disease ; because
they possess an organization or structure of parts peculiarly susceptible of
the morbid action wherein it consists.

To dwell, for, a moment, on this point, will be neither, we trust, useless
nor uninteresting.

Pulmonary consumption is a disease of the lungs, and is known to attack
such children or descendants, as resemble, particularly in the form and struc-
ture of the chest, their parents or ancestors who had been previously sub-
ject to it. Hence it is considered a hereditary complaint.

Madness is a disease of the brain, and is communicated from parents to
their children, along with a similarity of countenance and person. It is, in
like manner, therefore, called hereditary.

Gout passes also most readily to those descendants who most resemble
such of their ancestors as had previously suffered from it. Our author, there-
fore, himself embraces, in his definition of it, its hereditary quality.

Rheumatism is a disease of the joints, prevails in some families much more
than in others; and, in these cases, attacks with most certainty those chil-
dren, who, in personal appearance, most strongly resemble such of their
ancestors as had been already subject to it. Why, then, is not it also re-
garded as hereditary ? Is a disease passing from parent to child, in conse-
quence of a similarity of brain and lungs, to be denominated hereditary ? and
shall the same title be denied to one that passes, in the same way, by means

296 PRACTICE OF PHYSIC.

433. It is the acute rheumatism which especially be-
longs to this place, as from its causes, symptoms, and
methods of cure, it will appear to be a species of phleg-
masia, or inflammation.

434. This disease is frequent in cold, and more un-
common in warm climates. It appears most frequently
in autumn and spring, less frequently in winter when the
cold is considerable and constant, and very seldom dur-
ing the heat of summer. It may occur, however, at any
season, if vicissitudes of heat and cold be for the time
frequent.

435. The acute rheumatism generally arises from the
application of cold to the body when anyway unusually
warm ; or when any part of the body is exposed to cold
whilst the other parts are kept warm ; or, lastly, when
the application of the cold is long continued, as it is
when wet or moist clothes are applied to any part of the
body.

436. These causes may affect persons of all ages; but
the rheumatism seldom appears in either very young or
in elderly persons, and most commonly occurs from the
age of puberty to that of thirty-five years.*

437. These causes (435.) may also affect persons of
any constitution; but they most commonly affect those of
a sanguine temperament.

438. This disease is particularly distinguished by
pains affecting the joints, for the most part the joints
alone, but sometimes affecting also the muscular parts.

of a similarity of joints and muscles? Re custom and fashion what they may,
we can perceive in nature no reason why this should be the case. It would
not, we think, be difficult to show, that there exists scarcely an argument in
proof of the hereditary nature of gout, which may not be urged with equal
pertinency in favour also of that of Rheumatism.

* We have seen not only children, but also persons far advanced in years,
labouring under very severe attacks of acute rheumatism. Chronic rheuma-
tism is known to be particularly incidental to the aged. It too often consti-
tutes one of the miseries of the evening of life.

PRACTICE OF PHYSIC. 291

Very often the pains shoot along the course of the mus-
cles, from one joint to another, and are always much in-
creased by the action of the muscles belonging to the
joint or joints affected.

439. The larger joints are most frequently affected,
such as the hip-joint and knees of the lower, and the
shoulders and elbows of the upper extremities. The
ankles and wrists are also frequently affected; but the
smaller joints, such as those of the toes or fingers, sel
dom suffer.

440. This disease, although sometimes confined to
one part of the body only, yet very often affects many
parts of it; and then it comes on with a cold stage,
which is immediately succeeded by the other symptoms
of pyrexia, and particularly by a frequent, full, and hard
pulse. Sometimes the pyrexia is formed before any
pains are perceived; but more commonly pains are felt
in particular parts, before any symptoms of pyrexia ap-
pear.*

441. When no pyrexia is present, the pain is some-
times confined to one joint only; but, when any consi-
derable pyrexia is present, although the pain may be
chiefly in one joint, yet it seldom happens but that the
pains affect several joints often at the very same time,
but for the most part shifting their place, and having
abated in one joint, become more violent in another.
They do not commonly remain long in the same joint,
but frequently shift from one to another, and sometimes
return to joints formerly affected; and in this manner
the disease often continues for a long time,

442. The pyrexia attending this disease has an ex-

* In this, as in all other general diseases, pyrexia arises from a local affec-
tion. It very rarely, therefore, precedes pain, and never irritation.- and we
have stated, on a former occasion, that a mere irritative affection is as capa-
ble of giving rise to general fever as a sensitive one.
VOL. I. p p

22$ PRACTICE OF PHYSIC.

acerbation every evening, and is most considerable dur-
ing the night, when the pains also become more violent;
and it is at the same time that the pains shift their place
from one joint to another. The pains seem to be also
increased during the night, by the body being covered
more closely, and kept warmer.

443. A joint, after having been for some time affected
with pain, commonly becomes affected also with some
redness and swelling, which is painful to the touch. It
seldom happens, that a swelling coming on does not alle-
viate the. pain of the joint; but. the swelling does not
always take off the pain entirely, nor secure the joint
against a return of it.*

444. This disease is commonly attended with some
sweating, which occurs early in the course of the dis-
ease; but it is seldom free or copious, and seldom either
relieves the pains or proves critical.

445. In the course of this disease the urine is high-
coloured, and in the beginning without sediment; but as
the disease advances, and the pyrexia has more consider-
able remissions, the urine deposits a lateritious sedi-
ment. This, however, does not prove entirely critical:
for the disease often continues long after such a sedi-
ment has appeared in the urine.

446. When blood is drawn in this disease, it always
exhibits the appearance mentioned (237.)

447. The acute rheumatism, though it has so much
of the nature of the other phlegmasia?, differs from all
those hitherto mentioned, in this, that it is not apt to
terminate in suppuration. This almost never happens

* In rheumatism the inflammation is primarily membranous. The swell-
ing that occurs is produced bv an effusion from the diseased and distended
vessels into the cellular substance by which they are surrounded. This ef-
fusion operates like a topical evacuation from the inflamed part, takes off
the tension from the labouring vessels, and, in this way, mitigates the seve-
rity of the pain.

PRACTICE OF PHYSIC. 299

in rheumatism; but the disease sometimes produces effu-
sions of a transparent gelatinous fluid into the sheaths
of the tendons. If we may be allowed to suppose that
such effusions are frequent, it must also happen, that
the effused fluid is commonly reabsorbed; for it has
seldom happened, and never indeed to my observation,
that considerable or permanent tumours have been
produced, or such as required to be opened, and to
have the contained fluid evacuated. Such tumours,
however, have occurred to others, and the opening made
.in them has produced ulcers difficult to heal. Vide
Storck. Ann. Med. II.*

448. With the circumstances mentioned from (438.
to 447.) the disease often continues for several weeks.
It seldom, however, proves fatal: and it rarely happens
that the pyrexia continues to be considerable for more
than two or three weeks. While the pyrexia abates in
its violence, if the pains of the joints continue, they are
less violent, more limited in their place, being confined
commonly to one or a few joints only, and are less ready
to change their place.

449. When the pyrexia attending rheumatism has
entirely ceased; when the swelling, and particularly the
redness of the joints, are entirely gone; but when pains
still continue to affect certain joints, which remain stiff,
which feel uneasy upon motion, or upon changes of
weather; the disease is named the Chronic Rheumatism,
as it very often continues for a long time. As the chro-
nic is commonly the sequel of the acute rheumatism,

* The inflammation in rheumatism is as much of a nature sui generis — as
specifically different from every other kind of inflammation, as is that of
■mall pox, kine pox or lues venerea. The difference of the diseased action
is conclusively manifested by the difference of its results, — rheumatic inflam-
mation, strictly so called, often, like that of gout, suddenly shifting from
place to place, and never terminating in suppuration or gangrene. When
it terminates in either, it is of a spurious kind.

300 PRACTICE OF PHYSIC.

I think it proper to treat of the former also in this
place.*

450. The limits between the acute and chronic rheu-
matism are not always exactly marked.

When the pains are still ready to shift their place;
when they are especially severe in the night-time; when,
at the same time, they are attended with some degree of
pyrexia, and with some swelling, and especially with
some redness of the joints; the disease is to be consi-
dered as still partaking the nature of the acute rheu-
matism.

But when there is no degree of pyrexia remaining;
when the pained joints are without redness; when they
are cold and stiff; when they cannot easily be made to
sweat; or when while a free and warm sweat is brought
out on the rest of the body, it is only clammy and cold
on the pained joints; and when especially, the pains of
these joints are increased by cold, and relieved by heat
applied to them; the case is to be considered as that of
a purely chronic rheumatism.f

451. The chronic rheumatism may affect different
joints; but is especially ready to affect those joints which
are surrounded with many muscles, and those of which
the muscles are employed in the most constant and vi-
gorous exertions. Such is the case of the vertebrae of
the loins, the affection of which is named Lumbago; or
that of the hip-joint, when the disease is named Ischias,
or Sciatica.

* We believe that in youthful persons, and even in those who have not
yet attained their forty-fifth year, the acute rheumatism, if properly treated,
never terminates in the chronic. Such a termination must be the result of
neglect or unskilful practice. Chronic rheumatism, induced under these
circumstances, can be nothing but an acute form of the disease imperfectly
cured-

f In this paragraph is drawn with a nice and masterly hand the line of dis-
crimination between acute and chronic rheumatism.

PRACTICE OF PHYSIC. 301

452. Violent strains and spasms occurring on sudden
and somewhat violent exertions, bring on rheumatic
affections, which at first partake of the acute, but very
soon change into the nature of the chronic rheumatism.

453. I have thus delivered the history of rheuma-
tism; and suppose, that, from what has been said, the
remote causes, the diagnosis, and prognosis of the dis-
ease, may be understood. The distinction of the rheu-
matic pains from those resembling them, which occur
in the syphilis and scurvy, will be obvious, either from
the seat of those pains, or from the concomitant symp-
toms peculiar to these diseases. The distinctions of
rheumatism from gout will be more fully understood
from what is to be delivered in the following chapter.*

454. With respect to the proximate cause of rheu-
matism, there have been various opinions. It has been
imputed to a peculiar acrimony ; of which, however, in
ordinary cases, I can find no evidence; and from the
consideration of the remote causes, the symptoms and
cure of the disease, I think the supposition very im-
probable.

The cause of an Ischias Nervosa assigned by Co-
tunnius, appears to me hypothetical, and is not sup-
ported by either the phenomena or method of cure.
That, however, a disease of a rheumatic nature may be
occasioned by an acrid matter applied to the nerves, is
evident from the tooth-ach, a rheumatic affection gene-
rally arising from a carious tooth.

That pains resembling those of rheumatism may
arise from deep-seated suppurations, we know from

* Notwithstanding all our author has here said, there occurs, at times, no
inconsiderable difficulty in distinguishing pains of a purely rheumatic charac-
ter from those connected with lues venerea, and perhaps also with scurvy.
To enable himself fairly to make up his mind on this subject, the physician
is often obliged to inquire very minutely into the previous history, habits
and practices of his patient.

302 PRACTICE OF PHYSIC.

some cases depending on such a cause, and which, in
tlnir symptoms, resemble the lumbago or ischias. I
believe, however, that by a proper attention, these cases
depending on suppuration, may be commonly distin-
guished from the genuine cases of lumbago and ischias;
and from what is said in (447.) I judge it to be at least
improbable, that a genuine lumbago or ischias does ever
end in suppuration.

455. The proximate cause of rheumatism has been
by many supposed to be a lentor of the fluids obstruct-
ing the vessels of the part; but the same consideration
as in (241. 1, 2, 3, 4, and 5.) will apply equally here
for rejecting the supposition of a lentor.

456. While I cannot, therefore, find either evidence
or reason for supposing that the rheumatism depends
upon any change in the state of the fluids, I must con-
clude, that the proximate cause of acute rheumatism, is
commonly the same with that of other inflammations
not depending upon a direct stimulus.

457. In the case of rheumatism, 1 suppose, that the
most common remote cause of it, thai is, cold applied,
operates especially on the vessels of the joints, from
these being less covered by a cellular texture than
those of the intermediate parts of the limbs. I suppose
further, that the application of cold p'roduces a con-
striction of the extreme vessels on the surface, and at
the same time an increase of tone or phlogistic diathe-
sis in the course of them, from which arises an increas-
ed impetus "of the blood, and, at the same time, a re-
sistance to the free passage of it, and consequently in-
flammation and pain. Further, I suppose, that the re-
sistance formed excites the vis medicatrix to a further
increase of the impetus of the blood; and, to support
this, a cold stage arises, a spasm is formed, and a py-

PRACTICE OF PHYSIC. 305

rexia and phlogistic diathesis are produced in the whole
system.*

458. According to this explanation, the cause of
acute rheumatism appears to be exactly analogous to
that of the inflammations depending on an increased
afflux of blood to a part while it is exposed to the ac-
tion of cold.

But there seems to be also, in the case of rheuma-
tism, a peculiar affection of the fibres of the muscles.

These fibres seem to be under some degree of rigi-
dity, and therefore less easily admit of motion; and are*
pained upon the exertions of it.

It is also an affection of these fibres which gives an
opportunity to the propagation of pains from one joint
to another, along the course of the muscles, and which
pains are more severely felt in the extremities of the
muscles terminating in the joints, because, beyond
these, the oscillations are not propagated.

This affection of the muscular fibres attending rheu-
matism, seems to explain why strains and spasms pro-
duce rheumatic affections; and, upon the whole, shows,
that, with an inflammatory affection of the sanguiferous
system, there is also in rheumatism a peculiar affection
of the muscular fibres, which has a considerable share
in producing the phenomena of the disease.f

* It will be perceived tliat our author delivers here his usual doctrine of
the proximate cause of'inflammation, in which is included his belief that the
blood moves through the inflamed vessels with an increased impetus In
this, we repeat, he must be mistaken. In every case of genuine inflamma-
tion there appears to be necessarily, in the diseased vessels, a diminished
rather than an increased rapidity and force in the movement of the blood.
This is true in relation to rheumatic inflammation, as well as to that of every
other kind.

f This rigidity of the fibres in rheumatism may be owing to a remora in
the fluids of what we might denominate the vasa fibvarum; or at least to
some species of disease in these vessels, in consequence of which they do
not secrete the fine mucus, or rather halitus, requisite to lubricate the parts,
and to enable them to move with the facility of health. For it is not impre-

304 PRACTICE OF PHYSIC.

459. Having thus given my opinion of the proximate
cause of rheumatism, I proceed to treat of the cure.

460. Whatever difficulty may occur with respect to
the explanation given, (457. and 458.) this remains
certain, that in acute rheumatism, at least in all those
cases which do not arise from direct stimuli, there is
an inflammatory affection of the parts, and a phlogistic
diathesis in the whole system; and upon these is found-
ed the method of cure, which frequent experience has
approved of.

461. The cure therefore requires, in the first place,
an antiphlogistic regimen, and particularly a total absti-
nence from animal food, and from all fermented or spi-
rituous liquors; substituting a vegetable or milk diet,
and the plentiful use of bland diluent drinks.*

462. Upon the same principle (449.) at least with
perhaps the same exception as above, blood-letting is
the chief remedy of acute rheumatism. The blood
ought to be drawn in large quantity, and the bleeding
is to be repeated in proportion to the frequency, ful-
ness, and hardness of the pulse, and to the violence of
the pain. For the most part, large and repeated bleed-
ings during the first days of the disease, seem to be ne-
cessary, and accordingly have been very much employ-
ed: but to this some bounds are to be set; for very
profuse bleedings occasion a slow recovery, and, if not

bable that each fibre is inclosed in a fine sheath similar to that of the muscle
to which it belongs, and requiring to be moistened and prepared for mo-
tion by a liquid secreted specifically for the purpose. Rheumatic inflam-
mation would seem to be to the vasa fibrarum, what phlegmonic inflamma-
tion is to the vessels belonging to the cellular membrane.

* In acute rheumatism accompanied with pyrexia, a milk diet is totally
inadmissible. Barley water, rice water, currant jelly dissolved in water,
and other articles, bland and purely vegetable, constitute the only sizable
diet in this disease. If any part of milk be allowable, it is the whey, pre-
pared by buttermilk, or some vegetable acid.

PRACTICE OF PHYSIC. 305

absolutely effectual, are ready to produce a chronic
rheumatism*

463. To avoid that debility of the system, which ge-
neral bleedings are ready to occasion, the urgent symp-
tom of pain may be often relieved by topical bleedings;
and especially when any swelling and redness have come
upon a joint, the pain of it may be very certainly re-
lieved by such bleedings; but, as the continuance of the
disease seems to depend more upon the phlogistic dia-
thesis of the whole system, than upon the affection of
particular parts, so topical bleedings will not always
supply the place of the general bleedings proposed
above.f

464. To take off the phlogistic diathesis prevailing in
this disease, purging may be useful, if procured by me-
dicines which do not stimulate the whole system, such
as the neutral salts, and which have, in some measure,
a refrigerant power. Purging, however, is not so pow-
erful as bleeding, in removing phlogistic diathesis; and
when the disease has become general and violent, fre-
quent stools are inconvenient and even hurtful, by the
motion and pain which they occasion. J

* We do not believe that " profuse bleedings" ever have been, or ever
can be, productive of" chronic rheumatism." As often as the acute is con-
verted into the chronic form of this disease, it is rather in consequence of a
deficiency than an excess of blood-letting-. As a liberal loss of blood pre-
vents peripneumony from terminating in empyema or hydrothorax, catarrh
in pulmonary consumption, and bilious remitting fever in hepatitis and
dropsy, so does it prevent the acute from terminating in the chronic form of
rheumatism.

j- Copious topical evacuations from the inflamed joints by leeches and
cups, although not to be resorted to as a substitute for general blood-let-
ting, is notwithstanding, when judiciously used, an invaluable auxiliary to it.
When the pain and inflammation, therefore, are great, it should never be
neglected.

* In pure rheumatism, we have rarely employed purgatives for any other
purpose, than to keep the bowels free from irritating contents. If carried
beyond this, they become inconvenient ; and, as we are inclined to believe,
do as much injury by the motion which they compel the patient to use, as

vol. I. q q

306 PRACTICE OF PHYSIC.

465. In acute rheumatism, applications to the pained
parts are of little service. Fomentations, in the beginning
of the disease, rather aggravate, than relieve the pains.
The rubefacients and camphire are more effectual in
relieving the pains; but generally they only shift the pain
from one part into another, and do little towards the cure
of the genera! affection. Blistering, applied to the pained
part, may also be very effectual in removing the pain
from it; but will be of little use, except where the pains
are much confined to one part.

466. The several remedies mentioned from 450. to
454. moderate the violence of the disease, and some-
ti es remove it entirely; but they sometimes fail in this,
and leave the cure imperfect. The attempting a cure by
large and repeated bleedings, is attended with many in-
conveniences, (see 140.) and the most effectual and
safe method of curing this disease, is, after some gene-
ral bleedings for taking off, or at least diminishing, the
phlogistic diathesis, to employ sweating, conducted by
the rules laid down (168. and 169,)*

they do good by their power of evacuation. In a disease so highly arterial as
that of rheumatism, and, in the production of which, the first morbific impres-
sion is usually made on the skin, they can, in no shape, be regarded as a
substitute fot blood-letting.

In case of cathartics being used in this disease, for the reduction of arte-
rial action, the saline purgatives are the most suitable. A solution of
Glauber's, Epsom, or llochelle salts, in a strong infusion of senna and manna
constitutes, for this purpose, one of the best preparations.

* Sweating in rheumatism, provided it be employed at the proper period
viz. after blood-letting has sufficiently reduced arterial action, is, in general
a valuable remedy. We have seen it, however, in some instances, very
fairly and extensively employed, without contributing much to weaken the
complaint. In such cases, blisters applied to the inflamed joints, after the
disease had been reduced, by general remedies, to somewhat of a local
character, were productive of salutary effects. But, blisters do no good—
they rather prove injurious, if applied while the symptoms of pyrexia are
high.

An excellent sweating formula is the nitrous powder combined with calo-
mel and tarlarized antimony, which v as formerly mentioned.
The hourly exhibition of a grain or two of ipecacuanha, combined with

PRACTICE OF PHYSIC. SOI

467. Opiates, except where they are directed to pro-
cure sweat, always prove hurtful in every stage of this
disease.

468. The Peruvian bark has been supposed a remedy
in some cases of this disease; but we have seldom found
it useful, and in some cases hurtful. It appears to me to
be fit in those cases only, in which the phlogistic dia-
thesis is already much abated, and where, at the same
time, the exacerbations of the disease are manifestly
periodical, with considerable remissions interposed

469. Calomel and some other preparations of mercury,
have been recommended in the acute rheumatism; but I
believe they are useful only in cases of the chronic kind,
or at least in cases approaching to the nature of these.

470. Having now treated fully of the cure of the
acute rheumatism, I proceed to treat of the cure of the
chronic, which is so frequently a sequel of the former.

471. The phenomena of the purely chronic rheuma-
tism, mentioned in 438. and 439. lead me to conclude,
that its proximate cause is an atony, both of the blood-
vessels and of the muscular fibres of the p rt affected,
together with a degree of rigidity and contraction in the
latter, such as frequently attends them in a state of atony.

472. Upon this view of the proximate cause the gen j-
ral indication of cure must be, to restore the activity
and vigour of the vital principle in the part; and the re-
medies for this disease, whi I) experience has approved
of, are chiefly such as are manifestly suited to the indi-
cation proposed.

ten or twelve grains of nitre, warm diluting drinks being given in the interim,
constitutes an excellent sudorific process. To this, to prevent sickness and
purging, we have sometimes advantageously added, from the sixth to the
tenth of a grain of opium. Heating sudorifics should be carefully avoided.
If the disease prove obstinate, the calomel and nitre may be very properly
continued until the gums become affected with the mercurial action. On
the occurrence of this, the symptoms of the complaint almost always give
way.

308 PRACTICE OF PHYSIC.

473. These remedies are either external or internal.
The external are, the supporting the heat of the part,

by keeping it constantly covered with flannel; the in-
creasing the heat of the part by external heat, applied
either in a dry or in a humid form; the diligent use of
the flesh-brush, or other means of friction; the applica-
tion of electricity in sparks or shocks; the application of
cold water by affusion or immersion ; the application of
essential oils of the most warm and penetrating kind;
the application of salt brine; and lastly, the employment
of exercise, either of the part itself so far as it can
easily bear it, or of the whole body by riding, or other
mode of gestation.*

474. Tho internal remedies are, 1. Large doses of es-

* To prove permanently useful, the electric fluid should be administered
in a much more continued form ; *. e. more frequently, and longer each
time, than is usually the case. If the patient be placed under its influence,
only from half an hour to an hour, each day, he will derive from it but little
advantage. So true is it, that a chronic disease can be removed only by a
chronic remedy.

Cold water applied : n the form of the shower-bath, if it does not produce
chilliness, but is succeeded by a pleasant glow on the surface of the body,
has been found very useful in chronic rheumatism. It gives tone to the skin,
hence to the stomach, and hence again to the whole system.

Bandaging the affected limb or part equably, but somewhat tightly, with
flannel rollers, proves exceedingly useful in the treatment of this disease.
It gives support to the muscles of the part, aids circulation in them, prevents
in them the sensation of fatigue, and thus restores to them their lost tone.
It produces, in fact, a new impression, whence proceeds a new action, which
effectually severs the morbid assopiation, wherein the disease consists. It
also aids in promoting perspiration.

As far as we are informed on the subject, this remedy was first used in
this city by the present professor of the theory and practice of physic in the
university of Pennsylvania.

When we come to speak of certain chronic affections of the bowels we
shall say that a similar remedy has been found extremely useful in their
treatment.

On the operation of the Juniperus Sabina, or Savin, in chronic rheuma-
tism, we are permitted, by the kindness of Dr. Chapman, to take from his
manuscript lectures, the following interesting and important extract :

" The Savin, in its operation on the system, produces the effects of a
warm, powerful, and diffusible stimulant, exciting all the secretions, with a
considerable determination to the surface.

PRACTICE OF PHYSIC. 309

sential oil drawn from resinous substances, such as tur-
pentine; 2. Substances containing such oils, as guaiac;

" Baffled in my attempts to cure some of the forms of chronic rheuma-
tism with the ordinary remedies, it is now upwards of five years, since I was
led, in consequence of my speculative notions, as to the powers of this me-
dicine, to experiment with it in this disease. During the period which has
subsequently elapsed, I have prescribed it very extensively, both in public
and private practice. The result of my numerous trials with it is such, that
I hope it will not be deemed the language of enthusiasm, when I declare,
that 1 hold it to be entitled to be placed at the very head of the remedies in
chronic rheumatism.

" But, for its successful application, it requires a very nice discrimination
in the selection of the proper cases.

" My enlarged experience with the medicine, has taught me some degree
of certainty in its use. It is still, however, not easy, by any general descrip-
tion, to impart the same sort of tact, or knowledge."

After a description of a form of rheumatism, in which there exists great
exhaustion of the system, with an unusual degree of coldness, and want of
action on the surface of the body, the professor subjoins the following prac-
tical remarks :

" Endued with properties, such as I have alleged it to possess, it was rea-
sonable to presume that the Savin would prove eminently serviceable in the
precise form of rheumatism which has been here described.

" The primary effects of the medicine, or, at least, its sensible effects, are,
to heat and stimulate the whole system, producing particularly a glow on
the surface, with much itching, and, ultimately, a slight perspiration, which,
however, seems to be extorted by the mere force of excitement. There are,
also, sometimes, miliary eruptions.

"The influence of the Savin over the circulation is prodigious. The
pulse, which, previously to its exhibition, is commonly small, weak, and ac-
celerated, now becomes full, active, and comparatively slow. No portion of
the system, indeed, seems to escape its wide pervading operation ; every
function being more or less invigorated, and especially some of the secretory
offices, as the urinary, the catamenial, and, perhaps, the seminal.

" Contrary to a very uniform law of the animal economy, by which it
seems to be ordained that the vigour of the arterial and lymphatic apparatus
should be in an inverse ratio, we have here indisputable evidence, in the
speedy removal of the chalky depositions, and of the various morbid growths
incident to the disease, of absorption being actively performed.

" After some days' continuance of the Savin, either from the mitigation of
the disease, or the positive tonic power which the medicine exerts, the situa-
tion of the patient is very considerably improved, as relates to his strength,
appetite, rest, and general sensations."

Encouraged by his successful use of Savin in one kind of chronic rheu-
matism, Dr. Chapman was led to administer it in another— that which is
usually denominated syphilitic. Here, again, his success was highly flatter-
ing; the disease being always alleviated, if not cured, by the remedy.

310 PRACTICE OF PHYSIC.

3. Volatile alkaline salts; 4. These, or other medicines
directed to procure sweat; (169.) and, lastly, calomel, or
other preparation of mercury, in small doses, continued
for some time.

On commencing the use of the Savin, in any case, the professor's practice
is, to administer to an adult from twelve to fifteen grains of the powdered
leaves, three times a-day. This dose he gradually increases, until an evident
effect is produced ; which sometimes, as he informs us, requires " three or
four times the quantity" with which he had begun.

In the treatment of chronic rheumatism, much good may be done by
clothing and exercise

The patient should wear, constantly, an entire covering of flannel, or fleecy
hosiery, next to the skin; and, if he be free from fever, take, during fine
weather, as much exercise in the open air, as he is able to bear without fa-
tigue. If he even exercise to such an extent as to produce a perspiration,
so much the better ; provided he be careful not to suffer himself to cool too
suddenly, or in a partial manner.

In addition to those already mentioned, many other remedies, both exter-
nal and internal, may be recommended as useful in chronic rheumatism.

Of the internal remedies, we may briefly enumerate the following :

Bruised Mustard-seed. — Of this, a table-spoonful may be taken at a dose,
and repeated twice or three times a-day.

Gum Guaiacum, in substance, or tincture. — Of the gum in powder, the dose
is from a scruple to half a drachm, to be taken from once to three times
a-day, according as the stomach and bowels may bear it. Of the tincture,
the volatile being preferable to the simple, a tea-spoonful may be taken
three or four times a-day. This Temedy proves most useful when it ope-
rates moderately on the bowels.

Sarsaparilla. — Of this, a drachm of the extract, or a decoction of half an
ounce of the root, may be taken at a dose, and repeated as often as circum-
stances may require. It is deemed valuable as a sudorific, and, therefore,
throws excitement on the skin.

Oxyde of Arsenic. — This article may be given either in powder or solu-
tion. Of the former, the dose may be from the eighth to the sixteenth of a
grain, and, of the latter, from six to eight, or ten drops, to be repeated, in
either case, four or five times a-day. This is a very powerful remedy, and
possesses strong anti rheumatic qualities.

Peruvian Bark. — This remedy, in common doses, either alone, or in com-
bination with Virginia snake-root, or gum guaiacum, and repeated seve-
ral times a-day, has acquired, with some practitioners, considerable reputa-
tion.

Mercury. — This, to prove effectual, should be administered in the usual
doses, until a gentle ptyalism be produced ; which, if the disease be of long
standing, ought to be continued for a considerable time.

Opium, given in iari^e and repeated doses, is said to have removed chro-
nic rheumatism in a few days. Combined with other articles, we have often
exhibited it in this complaint, with very pleasant and salutary effects.

PRACTICE OF PHYSIC. 31 1

475. These (462, 463.) are the remedies successfully
employed in the purely chronic rheumatism; and there
are still others recommended, as bleeding, general and
topical, burning, blistering, and issues: but these ap-
pear to me. to be chiefly, perhaps only, useful when
the disease still partakes of the nature of acute rheu-
matism.

An indigenous remedy, of considerable reputation, is the juice of the
berry of the Phytolacca decandria. Of (his, a small wine-glassful may be
taken two or three times a-day. Although our own experience in this pre-
paration has not been very extensive, we believe it to be an article of some
efficacy. To prevent the juice from fermenting and becoming sour, it should
be mixed, when expressed, with a little spirits of wine, or common brandy.

In addition to those already mentioned, the external remedies most in use,
and in highest estimation, are the warm, water or vapour bath, frictions with
the flesh-brush, or with some spirituous stimulating preparation, such as
camphorated, or volatile liniment, and cupping, sinapisms, blisters, or setons,
as near as convenient to the parts affected.

Tartarized Antimony, moistened with simple water, and briskly rubbed
with the hand on the diseased part, produces, after a few applications, which
should be made twice or thrice a-day, a crop of pustules of a peculiar ap-
pearance and character, and rarely fails to give great relief.

When other remedies have failed, travelling and change of climate, par-
ticularly a removal from a colder to a warmer climate, have effected a cure.
So has a change of life from a more sedentary to a more active.

A former resident of Philadelphia, with whom we are well acquainted, has
been, of late, entirely relieved from chronic rheumatism, by exchanging the
occupation of a manufacturer for that of a farmer. His habits, which, dur-
ing his first pursuit, were sedentary, are now active, and sometimes laborious.

In chronic rheumatism, the diet should be nutritive, but not heating. Vi-
nous and distilled liquors should be used very sparingly. In every instance
where the physical powers of the system are weakened, perfect temperance,
a mild climate, pure air, and moderate exercise, are the best restoratives.

.312 PRACTICE OF PHYSIC.

CHAPTER XIII.
OF THE TOOTHACH, OR ODONTALGIA.*

176. I HAVE formerly considered this disease as a
species of rheumatism, to be treated upon the same
principles as those delivered in the preceding chapter;

* On the subject of Odontalgia, we have but little to say ; our professional
experience in it being exceedingly limited.

"We are persuaded, however that Dr. Cullen is entirely mistaken respect-
ing its theory. It is in no way dependent on an acrimony of the humours.
Toothach, as a disease, is much more intimately connected with the stomach
than is generally imagined.

In corroboration of this, there is an abundance of evidence, accessible to
every one who may be inclined to go in quest of it.

The state of the teeth depends very essentially on that of the gums. If
the latter be in any measure diseased, it is almost impossible for the former
to be sound. But the condition of the gums is known to be materially in-
fluenced by that of the stomach. Although a sound state of the stomach
does not absolutely insure sound gums, because the latter organs may, like
other parts, be locally affected, yet, during a long continued disease of the
stomach, the gums rarely escape without injury. Hence it is, that dyspeptic
persons, and those who are subject to habitual costiveness, suffer so gene-
rally from carious teeth. Hence, also, the frequency of toothach in
pregnant and hysterical women, whose stomachs are almost constantly the
seat of disease.

The connexion between the teeth and the alimentary canal is very strik-
ingly manifested during the dentition of children. The diseases induced
in the stomach and bowels by that process, are known and acknowledged
by every physician. But the influence, it is reasonable to believe, is reci-
procal. If a diseased condition of the gums can disorder the primae viae, we
can have no ground to doubt of the reverse being true — the former must
sympathize with the sufferings of the latter.

Even in adults, we have known several instances wherein dyspeptic af-
fections remained intractable, until after the extraction of carious teeth;
when they suddenly disappeared without farther remedies.

The disease, Odontalgia, belongs to the class Neuroses, rather than to
that of pyrexiae ; it being very seldom accompanied with any febrile action.
But we feel persuaded, that when the science of pathology shall be better
understood, the stornach and alimentary canal will be acknowledged to be
the seat of that whole tribe of diseases, that are now called nervous. Per-
haps even their name will be ultimately changed, and they will be known

PRACTICE OF PHYSIC. 313

but now, from more attentive consideration, I am led to
consider the toothach as a distinct disease. Whilst the
most of what has been delivered in the last chapter pro-
ceeds upon the supposition that the rheumatism depends
upon a certain state of the blood-vessels, and of the mo-
tion of the blood in them, without this being produced
by the irritation of any acrid matter applied; I judge,
that in the toothach, though there are often the same
circumstances in the state of the blood-vessels as in the
cases of rheumatism, these circumstances in toothach
always arise from the application of an acrid matter to
the nerves of the teeth.

477. This disease is often no other than a pain felt in
a particular tooth, without any inflammatory affection
being at the same time communicated to the neighbour-
ing parts. This, however, is rarely the case ; and, for
the most part, together with the pain of the tooth, there
is some degree of pain and of inflammatory affection
communicated to the neighbouring parts, sometimes to

only by that of diseases of the prima viae. That toothach is a nervous disease,
appears from the fact, that it is oftentimes cured by the sight of the dentist ;
or by any other occurrence that produces a fright.

Women are much more subject than men to complaints of the stomacli
and bowels. So are they also to odontalgia and carious teeth. This would
seem to indicate a connexion between these two seats of disease.

Emetics, given for other purposes, have been known to afford great and
unexpected relief in the toothach. Without having ourselves ever tried
the experiment, we are inclined to believe that this would be very often, if
not generally, the case. The operation of an emetic would seldom fail to
cure, for the time, a fit of the toothach.

Such are the principal reasons, occurring to us, at present, which incline
us to believe that odontalgia is connected with a diseased stomach. In ad-
dition, then, to perfect cleanliness of the mouth, let those who wish to pre-
serve their teeth, be active in their endeavours to preserve a sound condi-
tion of the alimentary canal.

A diet of unripe and acid fruit, or of crude vegetable substances of any
other description, is injurious to the teeth. This effect it probably pro-
duces, much more through the medium of the stomach, than by its direct
action on the teeth themselves.

vol, i. r r

314 PRACTICE OF PHYSIC.

the whole of those on the same side of the head with
the affected tooth.

478. This inflammatory affection seems to me to be
always an affection of the muscles and of the membran-
ous parts connected with these, without any tendency
to suppuration; and such an affection, as is excited by
cold in similar parts elsewhere. It is from these cir-
cumstances that l conclude the affection to be of the
rheumatic kind.

479. It is possible that the muscles and membranes of
the jaw may be affected by the same causes which pro-
duce the rheumatism in other parts; and it is also pos-
sible, that a rheumatic diathesis at first produced by ir-
ritation, may subsist in the muscles and membranes of
the jaw, so that the inflammatory affection may be re-
newed by certain causes without any new application of
acrid matter. But I am persuaded that either of these
occurrences are very rare, and I have never been able
to ascertain any cases of toothach to be of these kinds.
I consider it, therefore, as highly probable, that this
rheumatic affection of the jaws which we name tooth-
ach, is always dependent upon some immediate applica-
tion of acrid matter to the nerves of the teeth.

480. It is however to be observed, that this applica-
tion of acrid matter does not always excite a pain in the
tooth itself, or an inflammatory affection of the neigh-
bouring parts; but that it very often operates by pro-
ducing a diathesis only ; so that cold applied to the neigh-
bouring parts does excite both a pain in the tooth, and
an inflammatory affection of the neighbouring parts
which did not appear before.

There seems to be also certain states of the body,
which operate upon the same diathesis so as to produce
toothach. Such seems to be the case of pregnant
women, who are more liable lo toothach than other

PRACTICE OF PHYSIC. 315

women. There are probably also some cases of in-
creased irritability, which render persons more subject
to toothach. Thus women are more liable to the dis-
ease than men, and particularly women liable to hys-
teric affections.

481. The acrid matter producing this disease, seems
to be generated first in the hard substances of the teeth:
and as it often appears first upon the external surface of
these, it might be suspected to arise from the applica-
tion of external matters to the teeth. But as the pro-
duction of this acrimony is often begun in the internal
cavity of the teeth, where the operation of external mat-
ters cannot be suspected, and as even when it begins
upon the external parts of the teeth, the operation of
the cause is at first in a small portion of the teeth only,
that it is difficult to suppose that any matter externally
applied could act in such a partial manner; so it is pre-
sumed that the acrid matter occasioning the toothach,
is produced by some vice originating in the substance of
the tooth itself. When it begins upon the external sur-
face, it is on the enamel ; but upon the internal surface,
it must be in the bony part. From what cause it arises
in either of these substances, I do not at all know; but
I suspect that it often arises from some more general
fault in the fluids of the body. The frequent use of
mercury, especially when thrown much upon the mouth,
and the state of the fluids in scurvy, seem both of them
to give a disposition to a caries in the teeth; and it is
possible that some other acrimonious states of the fluids
may have the same effect.

482. A caries in some part of the teeth, whether aris-
ing upon their internal surface, or uponth ir external,
proceeding so far as to reach the nerves in the cavity of
the teeth, is pretty manifestly the cause of toothach, and
of the first attacks of it; but when the cavity of the teeth

316 PRACTICE OF PHYSIC.

has been opened, so that the external air or other matters
can reach that cavity, these are often the exciting causes
of toothach, and serve to prove in general, that acrid
matters applied to the nerves occasion the disease.

483. What is the nature of the matter produced in
the caries of the teeth, I do not understand, nor have I
found any proper corrector of it ; but I presume it to be
of the putrid kind, as it often taints the breath with a
fetid odour.

484. In the cure of this disease, a long experience has
shown, that the extraction of the carious tooth proves
the most effectual, and very often the only effectual, re-
medy of the disease. But as in some cases this extrac-
tion is not proper, and as in many cases it is obstinately
avoided, other means of curing the disease, or at least
of relieving the pain, have been sought for and much
practised.

485. Among these remedies, those are likely to be
the most effectual which entirely destroy the affected
nerve, or at least so much of it as is exposed to the
action of the acrid matter in the tooth. When an open-
ing is made into the cavity of the tooth, the nerve of it
may be destroyed most certainly by the actual cautery;
and it may also possibly be done by the application of
potential caustics, either of the alkaline or acid kind.

486. When these remedies cannot be rendered effec-
tual, relief may often be obtained by diminishing the
sensibility of the nerve affected, by the application of
opium, or of the more acrid aromatic oils, and directly
to the nerve in the tooth. It appears also, that the sensi-
bility of the affected nerve may often be for some time
diminished by the external application of opium to the
extremities of those nerves in the skin, which are

PRACTICE OF PHYSIC. 317

branches of the same fifth pair of nerves with those of
the teeth.*

487. When the disease consists entirely in a pain of
the nerve of the tooth, without any considerable affec-
tion communicated to the neighbouring parts, the
remedies already mentioned are those especially to be
employed-, but when the disease consists very much in
an inflammatory affection of the muscles and membranes
of the jaw, and when at the same time there is little or
no access for the above-mentioned remedies to the
affected nerve, other measures are to be employed for
relieving the disease.

- 488. If the disease be attended with any general phlo-
gistic diathesis of the system, or with any considerable
degree of pyrexia, a general bleeding may be useful in
relieving the disease: but these circumstances occur
very rarely, and the disease is for the most part a purely
topical affection; in which, as I observed before, a
general bleeding is of very little service. As this dis-
ease, however, is a topical inflammation, it might be
supposed that topical bleedings would be very useful,
and sometimes they are so; but it is seldom that their
effects are either considerable or permanent. The
reasons of this I take to be, that the disease does not
consist in an affection of the blood-vessels alone, as in
the ordinary cases of rheumatism; but in a peculiar
affection of the fibres both ef the muscles and of the
vessels of the part induced by irritation. The in-
efficacy of topical bleedings is with me a proof of the
disease being of the latter kind.

* In a case of toothach, a small portion of the oleum origani, or of the
essential oil of cloves, introduced into the cavity of the carious tooth, seldom
fails to afford, at least, a temporary relief. So, if used in the same way, does
opium, camphor, alkohol, and various other stimulating substances. But,
by irritating and inflaming the gums, with which they cannot fail to come in
contact, we apprehend that these articles, if long continued, increase, a f
length, the malady they are intended to. relieve.

318 PRACTICE OF PHYSIC.

489. The remedies therefore necessary to give relief
in this disease, are those which take off the spasm of the
vessels, and especially of the muscles and membranes
affected. Such are blistering, brought as near to the part
affected as can be conveniently done; and such are also
increased excretions excited in the neighbouring parts,
as of the saliva and mucus of the mouth by the use of
acrid masticatories. It is often sufficient to excite a strong
sensation in the neighbouring parts ; as by eau de luce,
Spirit of lavender, or Hungary water snuffed up the
nostrils; or by the vitriolic aether properly applied to
the cheek. It is upon the same footing that I suppose
brandy or other ardent spirit held in the mouth is often
of service.*

490. There are cases of toothach in which it does not
appear that the disease arises from an acrid matter im-
mediately applied to the nerve of a tooth; but from the
external application of cold, or some other causes im-
mediately applied to the muscles and membranes of the
jaw; and which therefore seem to require some remedies
different from those above mentioned. But in all sucli
cases, it is to be suspected, that the effects of cold, or
of other such causes, are owing to a diathesis produced
by an acrid matter applied to the nerve of a tooth, and
continuing in some measure to act there ; and we have
accordingly often found, that the action of those external
causes were to be obviated only by the extraction of the
tooth from which the diathesis had arisen.

* Blisters, or sinapisms, applied to the cheek, or behind the ear, afford,
frequently, great relief to an aching tooth.

The chewing of such acrid, stimulating substances, as make a strong im-
pression on the mouth and fauces, and provoke a copious secretion of saliva,
produces, for the most part, a similar effect. So does the scarification of the
gum around the tooth.

These, however, are but palliative remedies. The only one from which
a radical cure is to be expected, is, the extraction of the tooth.

PRACTICE OF PHYSIC. 319

CHAPTER XIV.
OF THE GOUT.*

491. THE Gout, not only as it occurs in different per-
sons, but even as it occurs in the same person at differ-
ent times, is a disease of such various appearance, that
it is difficult to render the history of it complete and
exact, or to give a character of it that will universally
apply. However, I shall endeavour to describe the dis-
ease as it most commonly appears, and to mark the
varieties of it as well as I can. From such a history I
expect that a general character may be given ; and such
I think is the following, as given in the last edition of
our Nosology:

Gen. XXIII. Podagra. — Morbus hasreditarius, ori-
ens sine causa externa evidente, sed prseeunte plerum-
que ventriculi affectione insolita; pyrexia; dolor ad
articulum et plerumque pedis pollici, certe pedum et
manuum juncturis, potissimum infestus; per intervalla
revertens, et saepe cum ventriculi, vel aliarum interna-
rum partium affectionibus alternans.

492. The Gout is generally a hereditary disease: but

* Gout, more than almost any other disease, may be considered as growing
literally out of the stomach.

Whether it arise from a hereditary predisposition, from a long continued
and laborious pursuit of letters, or from an inordinate devotion to the plea-
sures of the table, or of love, the stomach is the organ that primarily suffers.
It is there that the symptoms of an approaching paroxysm are first felt ; and
to the same part alone, can remedies for it be directed, with any reasonable
prospect of advantage. Applications to other parts afford relief; but if a
cure by medicines ever be obtained, it must come from the stomach.

We are apprehensive that women are as liable to this disease as men ; but
they are attacked by it in a different shape ; which is not, therefore, gene-
rally recognised as gout. What would be regular podagra in men, is colic,
hysteria, sick headach, or some such anomalous complaint, in women.

320 PRACTICE OF PHYSIC.

some persons, without hereditary disposition, seem to
acquire it; and, in some a hereditary disposition may be
counteracted by various causes. These circumstances
may seem to give exceptions to our general position;
but the facts directly supporting it are very numerous.

493. This disease attacks especially the male sex: but
it sometimes, though more rarely, attacks also the fe-
male. The females liable to it are those of the more ro-
bust and full habits ; and it very often happens to such
long before the menstrual evacuation has ceased. I have
found it occurring in several females, whose menstrual
evacuations were more abundant than usual.

494. This disease seldom attacks eunuchs, and when
it does, they seem to be those who happen to be of a
robust habit, to lead an indolent life, and to live very
full.

495. The gout attacks especially men of robust and
large bodies, men of large heads, of full and corpulent
habits, and men whose skins are covered with a thicker
rete mucosum, which gives a coarser surface.

496. If with the ancients, we might ascertain, by cer-
tain terms, the temperaments of men, I would say, that
the gout attacks especially men of a cholerico-sanguine
temperament, and that it very seldom attacks the purely
sanguine or melancholic. It is, however, very difficult to
treat this matter with due precision.

497. The gout seldom attacks persons employed in
constant bodily labour, or persons who live much upon
vegetable aliment. It is also said to be less frequent
among those people who make no use of wine or other
fermented liquors.

498. The gout does not commonly attack men, till
after the age of five-and-thirty; and generally not till a
still later period. There are indeed instances of the gout
occurring more early; but these are few in comparison

PRACTICE OF PHYSIC. 321

of the numbers which agree with what we have given
as the general rule. When the disease does appear
early in life, it seems to be in those in whom the here-
ditary disposition is very strong, and to whom the re-
mote causes to be hereafter mentioned have been ap-
plied in a considerable degree.*

499. As the gout is a hereditary disease, and affects
especially men of a particular habit, its remote causes
may be considered as predisponent and occasional.

500. The predisponent cause, so far as expressed by
external appearances or by the general temperament, we
have already marked; and physicians have been very
confident in assigning the occasional causes: but, in a
disease depending so much upon a predisposition, the
assigning occasional causes must be uncertain; as in the
predisposed, the occasional causes may not always ap-"
pear, and in persons not predisposed, they may appear
without effect. This uncertainty must particularly affect
the case of the gout; but I shall offer what appears to
me most probable on the subject.

501. The occasional causes of the gout seem to be
of two kinds. First, those which induce a plethoric
state of the body. Secondly, those which, in plethoric
habits, induce a state of debility.

502. Of the first kind are a sedentary indolent man-
ner of life, a full diet of animal food, and the large use
of wine or of other fermented liquors. These circum-
stances commonly precede the disease; and if there
should be any doubt of their power of producing it,
the fact, however, will be rendered sufficiently proba-
ble by what has been observed in 497.

503. Of the second kind of occasional causes which

* We have known a boy of about six years old to sustain a regular parox-
ysm of podagra. For several generations gout had been a disease ef his pa-
"ernal ancestors.

VOL. J-. S a

322 PRACTICE OF PHYSIC,

induce debility are, excess in venery; intemperance in
the use of intoxicating liquors; indigestion, produced
either by the quantity or quality of aliments; much ap-
plication to study or business; night watching; exces-
sive evacuations; the ceasing of usual labour; the sud-
den change from a very full to a very spare diet; the
large use of acids and acescents; and, lastly, cold ap-
plied to the lower extremities.*

504. The first (502.) seem to act by increasing the
predisposition. The last (503.) are commonly the ex-
citing causes, both of the first attacks, and of the re-
petitions of the disease.

505. It is an inflammatory affection of some of the
joints, which especially constitutes what we call a pa-
roxysm of the gout. This sometimes comes on sud-
denly without any warning, but is generally preceded
by several symptoms; such as the ceasing of a sweating
which the feet had been commonly affected with be-
fore; an unusual coldness of the feet and legs; a fre-
quent numbness, alternating with a sense of prickling
along the whole of the lower extremities; frequent
cramps of the muscles of the legs; and an unusual tur-
gescence of the veins.

506. While these symptoms take place in the lower
extremities, the whole body is affected with some de-
gree of torpor and languor, and the functions of the sto-
mach in particular are more or less disturbed. The
appetite is diminished, and flatulency, or other symp-
toms of indigestion, are felt. These symptoms, and
those of 505. take place for several days, sometimes
for a week or two, before a paroxysm comes on ; but

* None of these causes ever produces gout, until it has first impaired the
fone of the stomach. But when the sound state of that organ has given
way, gout is likely very soon to follow.

PRACTICE OF PHYSIC. 323

commonly, upon the day immediately preceding it, the
appetite becomes greater than usual.

507. The circumstances of paroxysms are the fol-
lowing. They come on most commonly in the spring,
and sooner or later, according as the vernal heat suc-
ceeds sooner or later to the winter's cold; and perhaps
sooner or later also according as the body may happen
to be more or less exposed to vicissitudes of heat and
cold.

508. The attacks are sometimes felt first in the even-
ing, but more commonly about two or three o'clock oi
the morning. The paroxysm begins with a pain affect-
ing one foot, most commonly in the ball or first joint of
the great toe, but sometimes in other parts of the foot.
With the coming on of this pain, there is commonly
more or less of a cold shivering, which, as the pain in-
creases, gradually ceases, and is succeeded by a hot
stage of pyrexia, which continues for the same time
with the pain itself. From the first attack, the pain be-
comes by degrees more violent, and continues in this
state, with great restlessness of the whole body, till next
midnight, after which it gradually remits; and, after it
has continued for twenty-four hours from the com-
mencement of the first attack, it commonly ceases very
entirely, and, with the coming on of a gentle sweat, al-
lows the patient to fall asleep. The patient, upon com-
ing out of this sleep in the morning, finds the pained
part affected with some redness and swelling, which,
after having continued for some days, gradually abate.

509. When a paroxysm has thus come on, although
the violent pain after twenty-four hours be considerably
abated, the patient is not entirely relieved from it. For
some days he has every evening a return of more con-
siderable pain and pyrexia, and which continue with
more or less violence till morning. After continuing

32 t PRACTICE OF PHYSIC.

in this manner for several clays, the disease sometimes
goes entirely off, not io return till after along interval.

510. When the disease, after having thus remained
for some time in a joint, ceases very entirely, it gene-
rally leaves the person in very perfect health, enjoying
greater ease and alacrity in the functions of both body
and mind, than he had for a long time before expe-
rienced*

511. At the beginning of the disease, the returns of
it are sometimes only once in three or four years: but,
after some time, the intervals become shorter, and the
attacks become annual; afterwards they come twice
each year, and at length recur several times during the
whole course of autumn, winter, and spring; and as it
happens that, when the fits are frequent, the paroxysms
become also longer, so, in the advanced state of the
disease, the patient is hardly ever tolerably free from
it, except perhaps for two or three months in summer.

512. The progress of the disease is also marked by
the parts which it affects. At first, it commonly affects
one foot only; afterwards every paroxysm affects both
feet, the one after the other; and as the disease conti-
nues to recur, it not only affects both feet at once, but
after having ceased in the foot which was secondly at-
tacked, returns again into the foot first affected, and per-
haps a second time also into the other. Its changes of
place are not only from one foot to the other, but also
from the feet into other joints, especially those of the
upper and lower extremities; so that there is hardly a
joint of the body that is not, on one occasion or other,
affected. It sometimes affects two different joints at
the same time; but more commonly it is severe in a sin-
gle joint only, and passes successively from one joint to

* The morbid irritation under which the stomach had laboured, is no:v
-gone, and the system enjoys uninterrupted health.

PRACTICE OF PHYSIC, 325

another; so that the patient's affliction is often protracted
for ;i long time.

513. When the disease has often returned, and the
paroxysms have become very frequent, the pains are
commonly less violent than they were at first; but the
patient is more affected with sickness, and the other
symptoms of the atonic gout, which shall be hereafter
mentioned.*

514. After the first paroxysms of the disease, the
joints which have been affected are entirely restored to
their former suppleness and strength: but after the dis-
ease has recurred very often, the joints affected do nei-
ther so suddenly nor so entirely recover their former
state, but continue weak and stiff; and these effects at
length proceed to such a degree, that the joints lose
their motion altogether.

515. In many persons, but not in all, after the disease
has frequently recurred, concretions of a chalky nature
are formed upon the outside of the joints, and for the
most part immediately under the skin. The matter
seems to be deposited at first in a fluid form, but after-
wards becomes dry and firm. In their dry state, these
concretions are a friable earthy substance, very entirely
soluble in acids. After they have been formed, they
contribute, with other circumstances, to destroy the
motion of the joint.

516. In most persons who have laboured under the
gout for many years, a nephritic affection comes on, and
discovers itself by all the symptoms which usually at-
tend calculous concretions in the kidneys, and which
we shall have occasion to describe in another place.
All that is necessary to be observed here is, that the

* As the stomach becomes more and more weakened, it is less able to
throw the disease completely on another part of the system. Hence it is
obliged constantly to retain some portion of it itself.

326 PRACTICE OF PHYSIC.

nephritic affection alternates with paroxysms of the
gout; and that the two affections, the nephritic and the
gouty, are hardly ever present at the same time. This
also may be observed, that children of gouty or nephri-
tic parents commonly inherit one or other of these
diseases; but which ever may have been the principal
disease of the parent, some of the children have the
one, and some the other. In some of them, the ne-
phritic affection occurs alone, without any gout super-
vening; and, this happens to be frequently the case of
the female offspring of gouty parents.

517. In the whole of the history already given, I have
described the most common form of the disease; and
which therefore, however diversified in the manner I
have said, may be still called the regular state of the
gout. Upon occasion, however, the disease assumes
different appearances; but, as I suppose the disease to
depend always upon a certain diathesis or disposition of
the system; so every appearance which we can per-
ceive to depend upon that same disposition, I shall con-
sider as a symptom and case of the gout. The princi-
pal circumstance in what we term the Regular Gout,
is the inflammatory affection of the joints; and, what-
ever symptoms we can perceive to be connected with,
or to depend upon, the disposition which produces that
inflammatory affection, but without its taking place, or
being present at the same time, we name the Irregular
Gout*

518. Of such irregular gout there are three different

* Young practitioners ought to be exceedingly attentive to the irregular
forms, or appearances of gout, lest they should mistake them for some
other disease. Such mistake might lead to a practice discreditable to them-
selves, and injurious to their patients. The history of the sick, connected
with that of their family and ancestors, will generally enable a physician of
discernment to determine with correctness, whether their complaint be
gout or not. To these circumstances let practitioners, particularly at the
commencement of their professional course, pay the strictest attention.

PRACTICE OF PHYSIC. 327

states, which I name the atonic, the retrocedent, and the
misplaced gout.

519. The atonic state is when the gouty diathesis pre-
vails in the system, but, from certain causes, does not
produce the inflammatory affection of the joints. In
this case, the morbid symptoms which appear are
chiefly affections of the stomach; such as, loss of appe-
tite, indigestion, and its various circumstances of sick-
ness, nausea, vomiting, flatulency, acrid eructations, and
pains in the region of the stomach. These symp-
toms are frequently accompanied with pains and cramps
in several parts of the trunk, and the upper extremities
of the body, which are relieved by the discharge of wind
from the stomach. Together with these affections of
the stomach, there commonly occurs acostiveness; but
sometimes a looseness with colic pains. These affec-
tions of the alimentary canal are often attended with
all the symptoms of hypochondriasis; as dejection of
mind, a constant and anxious attention to the slightest
feelings, an imaginary aggravation of these, and an ap-
prehension of danger from them.

In the same atonic gout, the viscera of the thorax
also are sometimes affected, and palpitations, faintings,
and asthma, occur.

In the head also occur, headachs, giddiness, apoplec-
tic and paralytic affections.*

520. When the several symptoms now mentioned
occur in habits having the marks of a gouty disposition,
this maybe suspected to have laid the v foundation of
them, and especially when either, in such habits, a
manifest tendency to the inflammatory affection has
formerly appeared; or when the symptoms mentioned

* We believe that a great majority of apoplectic and paralytic cases are
nothing else than irregular gout. They certainly have their seat in the sto-
mach, and attack the brain through the medium of sympathy. Hence thr
importance of plentiful purging in them

328 PRACTICE OF PHYSIC.

are intermixed with, and are relieved by, some degree
of the inflammatory gout. In such cases there can be no
doubt of considering the whole as a state of the gout.

521. Another state of the disease I name the retro-
cedent gout. This occurs when an inflammatory state
of the joints has, in the usual manner, come on, but
which, without arising to the ordinary degree of pain
and inflammation, or, at least, without these continuing
for the usual time, and receding gradually in the usual
manner, they suddenly and entirely cease, while some
internal part becomes affected. The internal part
most commonly affected is the stomach, which is then
affected with anxiety, sickness, vomiting, or violent
pain; but sometimes the internal part is the heart,
which gives occasion to a syncope; sometimes it is the
lungs which are affected with asthma; and sometimes
it is the head, giving occasion to apoplexy or palsy. In
all these cases, tiiere can be no doubt of the symptoms
being all a part of the same disease, however different
the affection may seem to be in the parts which it at-
tacks.

522. The third state of irregular gout, which we
name the misplaced, is when the gouty diathesis, in-
stead of producing the inflammatory affection of the
joints, produces an inflammatory affection of some in-
ternal part, and which appears from the same symp-
toms that attend the inflammation of those parts arising
from other causes.

Whether the gouty diathesis does ever produce such
inflammation of the internal parts without having first
produced it in the joints, or if the inflammation of the
internal part be always a translation from the joints
previously affected, I dare not determine; but, even
supposing the latter to be always the case, I think the
difference of the affection of the internal part must still

PRACTICE OF PHYSIC. 329

distinguish the misplaced from what I have named the
retrocedent gout*

523. What internal parts may be affected by the
misplaced gout I cannot precisely say, because I have
never met with any cases of the misplaced gout in my
practice; and I find no cases of it distinctly marked by
practical writers, except that of a pneumonic inflamma-
tion.

52 4 There are two cases of a translated gout; the
one of which is an affection of the neck of the blad-
der, producing pain, strangury, and a catarrhus vesicas:
The other is an affection of the rectum, sometimes by
pain alone in that part, and sometimes by hsemorrhoi-
dal swelling there. In gouty persons, I have known
such affections alternate with inflammatory affection of
the joints: but whether to refer those affections to the
retrocedent, or to the misplaced gout, I will not pre-
sume to determine.

525. From the history which I have now delivered
of the gout, I think it may be discerned under all its
various appearances. It is, however, commonly sup-
posed, that there are cases in which it may be difficult
to distinguish gout from rheumatism, and it is possible
there may be such cases: but, for the most part, the
two diseases may be distinguished with great certainty
by observing the predisposition, the antecedents, the
parts affected, the recurrences of the disease, and its
connexion with the other parts of the system; which
circumstances, for the most part, appear very differ-
ently in the two diseases.f

* Our author's remarks on the misplaced gout are vague and unsatisfac.
tory— wholly insufficient to establish it as a stated form of the disease. For
aught he has said on the subject, it might be rejected entirely from systems
of nosology, and none but the atonic and retrocedent forms of irregular gout
be retained.

f We apprehend the most radical and essential difference between gout
VOL. I. T t

330 PRACTICE OF PHYSIC.

526. With respect to the gout, our next business is
to investigate its proximate cause; which must be a
difficult task, and I attempt it with some diffidence.

527. Upon this subject, the opinion which has ge-
nerally prevailed is, that the gout depends upon a cer-
tain morbific matter, always present in the body; and
that this matter, by certain causes, thrown upon the
joints or other parts, produces the several phenomena
of the disease.

528. This doctrine, however ancient and general,
appears to me very doubtful; for,

First, There is no direct evidence of any morbific
matter being present in persons disposed to the gout.
There are no experiments or observations which show
that the blood, or other humours of gouty persons, are
in any respect different from those of other persons,
Previous to attacks of the gout, there appear no marks
of any morbid state of the fluids; for the disease gene-
rally attacks those persons who have enjoyed the most
perfect health, and appear to be in that state when the
disease comes on. At a certain period of the disease,
a peculiar matter indeed appears in gouty persons:

and rheumatism tobe, that the former always, and the latter never, originates
in the stomach. In rheumatism the stomach is diseased; but its affection
we believe to be, for the most part, secondary ,- whereas, in the gout, it is al-
ways primary.

Another well known difference is, that the gout usually attacks the smaller,
and the rheumatism the larger joints of the body. To this rule, however,
there exist exceptions; gout attacking, occasionally, almost every part of
the system.

The subjects of gout and rheumatism are, also, for the most part, differ-
ent from each other, in their stations, habits, and modes of life. Gout at-
tacks the wealthy and luxurious, who live at their ease; rheumatism those
n humbler circumstances, who pursue a laborious mode of life Gout is a
disease of more, rheumatism of less polished society. Hence the former is,
in a great measure, confined to cities ; whereas the latter assails, indiffer-
ently, the poor of cities, and the inhabitants of the country.

Had we leisure to pursue the inquiry, we could make it appear, that th<
inflammation of gout, like that of rheumatism, is of a specific character

PRACTICE OF PHYSIC. 331

515.) but this, which does not appear in every instance,
and which appears only after the disease has subsisted
for a long time, seems manifestly to be the effect, not
the cause, of the disease. Further, though there be
certain acrids, which, taken into the body, seem to ex-
cite the gout, (503.) it is probable that these acrids ope-
rate otherwise id exciting the disease, than by afford-
ing the material cause of it. In general, therefore,
there is no proof of any morbific matter being the cause
of the gout.

Secondly, The suppositions concerning the particu-
lar nature of the matter producing the gout, have been
so various and so contradictory to each other, as to al-
low us to conclude, that there is truly no proof of the
existence of any of them. With respect to many of
these suppositions, they are so inconsistent with che-
mical philosophy, and with the laws of the animal eco-
nomy, that they must be entirely rejected.

Thirdly, The supposition of a morbific matter being
the cause of the gout, is not consistent with the pheno-
mena of the disease, particularly with its frequent and
sudden translations from one part to another.

Fourthly, The supposition is further rendered impro-
bable by this, that, if a morbific matter did exist, its
operation should be similar in the several parts which it
attacks; whereas it seems to be very different, being sti-
mulant, and exciting inflammation in the joints, but se-
dative and destroying the tone in the stomach: which,
upon the supposition of particular matter acting in both
cases, is not to be explained by any difference in the
part affected.

Fifthly, Some facts, alleged in proof of a morbific
matter, are not sufficiently confirmed, such as those
which would prove the disease to be contagious. There
is, however, no proper evidence of this, the facts given

332 PRACTICE OF PHYSIC

being not only few, but exceptionable; and the negative
observations are innumerable.

Sixthly, Some arguments brought in favour of a
morbific matter, are founded upon a mistaken explana-
tion. The disease has been supposed to depend upon
a morbific matter because it is hereditary: but. the in-
ference is not just; for most hereditary diseases do not
depend upon any morbific matter, but upon a particu-
lar conformation of the structure of the body, transmit-
ted from the parent to the offspring; and this last appears
to be particularly the case in the gout. It may be also
observed, that hereditary diseases, depending upon a
morbific matter, always appear much earlier in life than
the gout commonly does.

Seventhly, The supposition of a morbific matter be-
ing the cause of the gout, has been hitherto useless, as
it has not suggested any successful method of cure.
Particular suppositions have often corrupted the prac-
tice, and have frequently led from those views which
might be useful, and from that practice which experi-
ence had approved. Further, though the supposition
of a morbific matter has been generally received, it has
been as generally neglected in practice. When the gout
has affected the stomach, nobody thinks of correcting
the matter supposed to be present there, but merely of
restoring the tone of the moving fibres.

Eighthly, The supposition of a morbific matter is
quite superfluous; for it explains nothing, without sup-
posing that matter to produce a change in the state of
the moving powers, and a change in the state of the
moving powers, produced by other causes, explains
every circumstance, without the supposition of a mor-
bific matter; and, to this purpose, it may be observed,
that many of the causes (503.) exciting the gout, do not
operate upon the state of the fluids, but directly and
solely upon that of the moving powers.

PRACTICE OF PHYSIC. 333

Lastly, The supposition of a morbific matter is also
superfluous; because, without any such supposition, I
think the disease can be explained in a manner more
consistent with its phenomena, with the laws of the ani-
mal economy, and with the method of cure which ex-
perience has approved.

I now proceed to give this explanation; but, before
entering upon it, I must premise some general observa-
tions.*

529. The first observation is, that the gout is a dis-
ease of the whole system, or depends upon a certain ge-
neral conformation and state of the body, which mani-
festly appears from the facts mentioned from 493. to
496. But the general state of the system depends
chiefly upon the state of its primary moving powers;
and therefore the gout may be supposed to be chiefly
an affection of these.f

530. My second observation is, that the gout is ma-
nifestly an affection of the nervous system; in which
the primary moving powers of the whole system are
lodged. The occasional or exciting causes (503.) are
almost all such as act directly upon the nerves and ner-
vous system; and the greater part of the symptoms of
the atonic or retrocedent gout are manifestly affections
of the same system, (519. and 521.) This leads us to

* The very name of Gout, being derived from the French word Goutc.
a drop — that of rheumatism, from the Greek word *psa>, to flow, convinces us
that, originally, both diseases were supposed to arise from a vitiation of the
fluids. But, for the reasons assigned by Dr. Cullen, in addition to what wc
have ourselves said, on several occasions, in opposition to the humoral pa-
thology in every shape, the hypothesis must be ultimately and for ever aban-
doned. Rheumatism, gout, and all other complaints, originate in the solids ;
the disease arising from the exclusion of respirable air from the lungs ex-
cepted.

f Gout is a disease of the whole system, -when it has become so by sympathy.
But ; like every other complaint, it is at first local. It commences in the sto-
mach, and spreads by degrees to the other parts of the body.

334 PRACTICE OF PHYSIC

seek for an explanation of the whole of the disease in
the laws of the nervous system, and particularly the
changes which may happen in the balance of its seve-
ral parts *

531. My third observation is, that the stomach, which
has so universal a consent with the rest of the system,
is the internal part that is the most frequently, and often
very considerably affected by the gout. The paroxysms
of the disease are commonly preceded by an affection
of the stomach; (506.) many of the exciting causes
(503.) act first upon the stomach; and the symptoms of
the atonic and retrocedent gout (519. 521.) are most
commonly and chiefly affections of the same organ.
This observation leads us to remark, that there is a ba-
lance subsisting between the state of the internal and
that of the external parts; and, in particular, that the
state of the stomach is connected with that of the ex-
ternal parts; (44.) so that the state of tone in the one
may be communicated to the other.

532. These observations being premised, I shall now
offer the following pathology of the gout.

In some persons there is a certain vigorous and ple-
thoric state of the system (495.) which, at a certain pe-
riod of life, is liable to a loss of tone in the extremities,
(498. 505.) This is in some measure communicated to
the whole system, but appears more especially in the
functions of the stomach, (506.) When this loss of tone
occurs while the energy of the brain still retains its vi-
gour, the vis medicatrix naturae is excited to restore the
tone of the parts; and accomplishes it by exciting an
inflammatory affection in some part of the extremities.
When this has subsisted for some days, the tone of the

* We have already observed, and here repeat, that the prima: viae, more
particularly the stomach, constitute the seat of that family of diseases that
are now called nervous.

PRACTICE OF PHYSIC. 335

extremities, and of the whole system are restored, and
the patient returns to his ordinary state of health, (510.)*

533. This is the course of things, in the ordinary
form of the disease, which we name the regular gout;
but there are circumstances of the body, in which this
course is interrupted or varied. Thus when the atony
(505. 506.) has taken place, if the reaction (508.) do not
succeed, the atony continues in the stomach, or perhaps
in other internal parts, and produces that state which
we have, for reasons now obvious, named the atonic gout.

534. A second case of variation in the course of the
gout is, when, to the atony, the reaction and inflamma-
tion have to a certain degree succeeded; but, from causes
either internal or external, the tone of the extremities,
and perhaps of the whole system, is weakened ; so that
the inflammatory state, before it had either proceeded to
the degree, or continued for the time, requisite for re-
storing the tone of the system, suddenly and entirely
ceases. Hence the stomach, and other internal parts,
relapse into the state of atony: and perhaps have this
increased by the atony communicated from the extre-

* This is just as correct and intelligible as most of our author's specula-
tions touching tiie proximate causes of disease. In other words, it is " voces
iiianx etpraterea niltil."

All we shall venture to say, at present, respecting the philosophy of gout,
is, that the disease begins at a point in the stomach, and extends by sympa-
thy to the rest of the system. But we do not pretend to understand either
the principles of this sympathetic extension, or the peculiar kind of morbid
action in which gout consists. A knowledge of these points is reserved for
a period of greater advancement in pathological science.

If gout be, as we believe and have pronounced it, a disease of a specific
character, it is then on a level with all other complaints of the same descrip-
tion — not -understood: for, by specific action, whether in physiology, pathology,
or therapeutics, we mean an ultimate fact — something that we do not com-
prehend, and cannot explain, in as much as we have no standard of compari-
son by which we can throw light on it, either to ourselves or others.

Irregular gout occurs, when, by debility, exhaustion, or other causes, the
chain of sympathy, if we may so express ourselves, between the stomach
and the lower extremities, :s interrupted or broken.

836 PRACTICE OF PHYSIC.

mities: All which appears in what we have termed the
retrocrdent gout.

535. A third case of variation from the ordinary
course of the gout, is, when, to the atony usually pre-
ceding, an inflammatory reaction fully succeeds, but
has its usual determination to the joints by some cir-
cumstances prevented; and is therefore directed to an
internal part, where it produces an inflammatory affec-
tion, and that state of things which we have named the
misplaced gout.

536. We have thus offered an explanation of the cir-
cumstances of the system in the several states of the
gout; and this explanation we suppose to be consistent
with the phenomena of the disease, and with the laws of
the animal economy. There are indeed, with respect to
the theory of the disease, several questions which might
be put, to which we have not given any answer. But,
though perhaps we could give an answer to many of
these questions, it does not here appear necessary; as at
present we intend only to establish such general facts,
with regard to this disease, as may lay a foundation for
the cure of it, so far as experience has enabled us to
prosecute it. Proceeding, therefore, upon the several
parts of the pathology given, as so many matters of fact,
I shall now consider what may be attempted towards the
cure of the disease.

537. In entering upon this, I must observe, in the
first place, that a cure has been commonly thought im-
possible; and we acknowledge it to be very probable,
that the gout, as a disease of the whole habit, and very
often depending upon original conformation, cannot be
cured by medicines, the effects of which are always very
transitory, and seldom extend to the producing any
considerable change of the whole habit.*

* Completely to eradicate a strong hereditary predisposition to gout, we

PRACTICE OF PHYSIC. 337

o38. It would perhaps have been happy for gouty
persons, if this opinion had been implicitly received by
them; as it would have prevented their having been so
often the dupes of self-interested pretenders, who have
either amused them with inert medicines, or have rashly
employed those of the most pernicious tendency. I am
much disposed to believe the impossibility of a cure of
the gout by medicines; and more certainly still incline
to think, that whatever may be the possible power of
medicines, yet no medicine for curing the gout has
hitherto been found. Although almost every age has
presented a new remedy, yet all hitherto offered have

believe to be as impracticable, as it would be to remove a hereditary like-
ness in feature or figure, complexion or size. It is so inextricably inter-
woven with the texture of certain organs, as to constitute, perhaps, essen-
tially, a part of the system. But, by steadily persevering in a suitable regi-
men, it may be, if not actually weakened, at least prevented from acquiring
any additional strength : while a cautious avoidance of exciting causes, will,
if not always, at least in most instances, effectually stay its progress towards
disease.

Our author's observations, on the regimen proper for persons predisposed
to gout ; are so sensible and pertinent, ample and clearly expressed, that any
addition to them might be deemed superfluous. They constitute as able a
manifestation of practical wisdom and professional skill, as is any where to
be found in the records of medicine.

We shall only further observe, that, whatever co-operates with temper-
ance in strengthening the system, particularly the stomach, and diminish-
ing susceptibility, may be usefully employed as a preventive of gout. Of
this description is travelling, and all manly and athletic exercises in the open
air : these, however, should never be carried to the point of fatigue. Mode-
ration in all things constitutes the true spirit of the regmen most suitable to
those who are subject to gout.

In persons whose predisposition to gout, instead of being hereditary, has
been created by their own voluptuous practices and luxurious living, a
change of life has effectually removed it.

It must be acknowledged, however, that such instances are not very com-
mon, and that success is always doubtful, where the meridian of life is al-
ready past, and there has been a long and zealous devotion to convivial
pleasures, to immoderate drinking, or to an excessive and illegitimate in-
dulgence in love. Under circumstances like these, .t is perfectly true, as
our author has stated, that a sudden change of life is neither a remedy uni-
formly effectual, in the cure of gout, nor altogether unaccompanied with
danger.

VOL. I. TT „

338 PRACTICE OF PHYSU

very soon been either neglected as useless, or con-
demned as pernicious.

539. Though unwilling to admit the power of medi-
cines, yet I contend that a great deal can be done to-
wards the cure of the gout bv a regimen: And from
what has been observed (497.) I am firmly persuaded,
that any man who, early in life, will enter upon the con-
stant practice of bodily labour, and of abstinence from
animal food, will be preserved entirely from the disease.

Whether there be any other means of radically curing
the gout I am not ready to determine. There are histo-
ries of cases of the gout, in which it is said, that by
great emotions of mind, by wounds, and by other accr-
dents, the symptoms have been suddenly relieved, and
never again returned; but how far these accidental cures
might be imitated by art, or would succeed in other
cases, is at least extremely uncertain.

540. The practices proper and necessary in the treat-
ment of the gout, are to be considered under two heads;
first, As they are to be employed in the intervals of
paroxysms; or, secondly, As during the time of these.

541. In the intervals of paroxysms, the indications
are, to prevent the return of paroxysms, or at least to
render them less frequent, and more moderate. During
the time of paroxysms, the indications are, to moderate
the violence, and shorten the duration of them as much
as can be done with safety.

542. It has been already observed, that the gout may
be entirely prevented by constant bodily exercise, and
by a low diet: and I am of opinion, that this prevention
may take place even in persons who have a hereditary
disposition to the disease. I must add here, that even
when the disposition has discovered itself by several
paroxysms of inflammatory gout, I am persuaded that
labour andabstinence will absolutely prevent any returns

PRACTICE OF PHYSIC. 339

it for the rest of life. These, therefore, are the means
of answering the first indication to be pursued in the in-
tervals of paroxysms; and I must here offer some re-
marks upon the proper use of these remedies.*

543. Exercise in persons disposed to the gout, is di-
rected to two purposes: One of these is the strength-
ening of the tone of the extreme vessels; ard the other
the guarding against a plethoric stat<\ For the former,
if exercise be employed early in life, and before intem-
perance has weakened the body, a very moderate de-
gree of it will answer the purpose; and for the latter, if
abstinence be at the same time observed", little exercise
will be necessary.

544. With respect to exercise, this in general is to be
observed, that it should never be violent; for if violent,
it cannot be long continued, and must always endanger
the bringing on an atony in proportion to the violence
of the preceding exercise.

545. It is also to be observed, that the exercise of
gestation, though considerable and constant, if it be
entirely without bodily exercise, will not answer the pur-
pose in preventing the gout. For this end, therefore,
the exercise must be, in some measure, that of the body,
and must be moderate, but at the same time constant
and continued through life.

546. In every case and circumstance of the gout, in
which the patient retains the use of his limbs, bodily
exercise, in the intervals of paroxysms, will always be
useful; and, in the beginning of the disease, when the

* The Baron Van Swieten mentions the case of a priest, who, enjoying a
rich living, had been an old and constant sufferer from the gout. But, being
made a captive by the pirates of Barbary, he was detained in slavery for two
years, and compelled to work in the galleys, supported only by a mesgre
diet. He was at length ransomed, and the result was, that having lost his
troublesome and cumbrous obesity, he had never afterwards a fit of the gout,
but lived many years in the enjoyment of uninterrupted health.

340 PRACTICE OF PHYSIC.

disposition to it is not yet strong, exercise may prevent
a paroxysm which otherwise might have come on. In
more advanced states of the disease, however, when
there is some disposition to a paroxysm, much walking
will bring it on ; either as it weakens the tone of the
lower extremities, or as it excites an inflammatory dis-
position in them; and it is probable, that in the same
manner strains or contusions often bring on a paroxysm
or the gout*

547. Abstinence, the other part of our regimen (539.)
for preventing the gout, is of more difficult application.
If an abstinence from animal food be entered upon early
in life, while the vigour of the system is yet entire, we
have no doubt of its being both safe and effectual; but if
the motive for this diet shall not have occurred till the
constitution shall have been broken by intemperance,
or by the decline of life, a low diet may then endanger
the bringing on an atonic state.

548. Further, if a low diet be entered upon only in
the decline of life, and be at the same time a very great
change in the former manner of living, the withdraw-
ing of an accustomed stimulus of the system may readily
throw this into an atonic state.f

549. The safety of an abstemious course may be
greater or less according to the management of it. It
is animal food which especially disposes to the plethoric
and inflammatory state, and that food is to be therefore
especially avoided ; but, on the other hand, it is vegetable
aliment of the lowest quality that is in danger of weak-
ening the system too much, by not affording sufficient

* We have seen several instances, in which, in those predisposed to the
disease, a strain or contusion of the foot has produced a regular paroxysm
of podagra. The injury in such cases acts only as the exciting cause.

f A sudden change from a full to a spare diet is mentioned, in article 503,
as one of the occasional causes of gout.

PRACTICE OF PHYSIC. 34 J

nourishment; and more particularly of weakening the
tone of the stomach by its acescency. It is therefore
a diet of a middle nature that is to be chosen ; and milk
is precisely of this kind, as containing both animal and
vegetable matter.

As approaching to the nature of milk, and as being a
vegetable matter containing the greatest portion of nou-
rishment, the farinaceous seeds are next to be chosen,
and are the food most proper to be joined with milk.

550. With respect to drink, fermented liquors are
useful only when they are joined with animal food, and
that by their acescency; and their stimulus is only ne-
cessary from custom. When, therefore, animal food is
to be avoided, fermented liquors are unnecessary; and,
by increasing the acescency of vegetables, these liquors
may be hurtful. The stimulus of fermented or spiritu-
ous liquors, is not necessary to the young and vigorous;
and, when much employed, impairs the tone of the sys-
tem. These liquors, therefore, are to be avoided, ex-
cept so far as custom and the declining state of the sys-
tem may have rendered them necessary. For prevent-
ing or moderating the regular gout, water is the only
proper drink.

551. With respect to an abstemious course, it has
been supposed that an abstinence from animal food and
fermented liquors, or the living upon milk and farinacea
alone for the space of one year, might be sufficient for a
radical cure of the gout; and it is possible that, at a
certain period of life, in certain circumstances of the
constitution, such a measure might answer the purpose.
But this is very doubtful; and it is more probable that
the abstinence must, in a great measure, be continued,
and the milk diet be persisted in, for the rest of life'
It is well known, that several persons who had entered
on an abstemious course, and had been thereby deli-

342 PRACTICE OF PHYSIC.

vered from the gout, have, however, upon returning to
their former manner of full living, had the disease re-
turn upon them, with as much violence as before, or in
a more irregular and more dangerous form.*

552. It has been alleged, that, for preventing the
return of the gout, blood-letting, or scarifications of
the feet frequently repeated, and at stated times, may
be practised with advantage; but of this I have had no
experience.

553. Exercise and abstinence are the means of avoid-
ing the plethoric state which gives the disposition to the
gout; and are therefore the means proposed for prevent-
ing paroxysms, or at least for rendering them less fre-
quent, and more moderate. But many circumstances
prevent the steadiness necessary in pursuing these mea-
sures; and therefore, in such cases, unless great care be
taken to avoid the exciting causes, the disease may fre-
quently return; and in many cases, the preventing of
paroxysms is chiefly to be obtained by avoiding those
exciting causes enumerated in 503. The conduct ne-
cessary for avoiding them, will be sufficiently obvious to
persons acquainted with the doctrines of the Hygieine,
which I suppose to have been delivered in another place.

55i. A due attention in avoiding those several causes,
(502. 503.) will certainly prevent fits of the gout; and
the taking care that the exciting causes be never applied
in a great degree, will certainly render fits more mode-
rate when they do come on. But, upon the whole, it
will appear, that a strict attention to the whole conduct
of life, is in this matter necessary; and therefore, when
the predisposition has taken place, it will be extremely
difficult to avoid the disease.

* It is exceedingly improbable that any regimen or mode of life persisted
in for only a year, and then abandoned, has ever effeeted, or ever will effect,
a radical cure of gout.

PRACTICE OF PHYSIC. 343

555. I am indeed firmly persuaded, that, by obviating
the predisposition, and by avoiding the exciting causes,
the gout may be entirely prevented: but as the measures
necessary for this purpose will, in most cases, be pur-
sued with difficulty, and even with reluctance, men have
been very desirous to find a medicine which might an-
swer the purpose without any restraint on their manner
of living. To gratify this desire, physicians have pro-
posed, and, to take advantage of it, empirics have feign-
ed, many remedies, as we have already observed. Of
what nature several of these remedies have been, I can-
not certainly say; but, of those which are unknown, we
conclude, from their having been only of temporary fame,
and from their having soon fallen into neglect, that they
have been either inert or pernicious, and therefore I
make no inquiry after them; and shall now remark only
upon one or two known remedies for the gout, which
have been lately in vogue.

556. One of these is what has been named in Eng-
land^ the Portland Powder. This is not a new medi-
cimvbut is mentioned by Galen, and, with, some little
variation in its composition, has been mentioned by the
writers of almost every age since that time. It appears
to have been at times in fashion, and to have again fallen
into neglect; and I think that this last has been owing
to its having been found to be, in many instances, per-
nicious. In every instance which I have known of its
exhibition for the length of time prescribed, the persons
who had taken it were indeed afterwards free from any
inflammatory affection of the joints; but they were af-
fected with many symptoms of the atonic gout; and all,
soon after finishing their course of the medicine, have
been attacked with apoplexy, asthma, or dropsy, which
proved fatal.*

* The Portland Powder being rejected from practice, both in Eurorr.

344 PRACTICE OF PHYSIC.

557. Another remedy which has had the appearance
of preventing the gout, is an alkali in various forms,
such as the fixed alkali both mild and caustic, lime wa-
ter, soap, and absorbent earths. Since it became com-
mon to exhibit these medicines in nephritic and calcu-
lous cases, it has often happened that they were given
to those who were at the same time subject to the gout;
and it has been observed, that under the use of these
medicines, gouty persons have been longer free from the
fits of their disease. That, however, the use of these
medicines has entirely prevented the returns of gout, I
do not know; because I never pushed the use of those
medicines for a long time, being apprehensive that the
long continued use of them might produce a hurtful
change in the state of the fluids.*

and America, an account of its composition would be altogether useless. It
consisted of several vegetable articles, all of them bitter, aromatic, or other-
wise stimulating, calculated, perhaps, to gn e, for a time, a factitious tone to
the stomach, but not to augment its natural powers. On the other hand, it
could no more fail to impair these powers, than the long continued and ex-
cessive use of ardent spirits, Cayenne pepper, or any other powerfully sti-
mulating condiment or drink. To say the least, it prevented one disease
of the stomach only by producing another.

* Several persons with whom we have conversed, fancy that their arthri-
tic complaints have been much relieved, by the daily and long continued
use of the hypercarbonated soda water.

That some of the troublesome symptoms of gout have been thus miti-
gated is probably true : but that the predisposition to the disease has ever
been materially weakened by this remedy, is a position, which, as far as we
are informed, there exists no satisfactory reason to believe. From the usual
operation of soda and other absorbents on the system, we would not be led
to consider them as efficacious remedies in the treatment of gout. We be-
lieve their introduction and employment to have arisen from a false theory
of the disease ; and that they have never yet received the sanction of expe-
rience. When gout was supposed to originate from the presence of a su-
perabundant acid in the system, alkalies and absorbents were resorted to
as its most promising and natural remedies. But it being now acknowledged
to be a disease of the solids, these remedies are no longer in such esteem.

" The Eau Medicinale d'Husson, (says a British practical writer of consi-
derable reputation,) is a remedy much in vogue, at present, in gouty at-
tacks, and in some cases it appears to have considerably alleviated the pa-

PRACTICE OF PHYSIC. 345

o58 With respect to preventing the gout I have only
One other remark to offer, As the preventing the gout
depends very much on supporting the tone of the sto-
mach, and avoiding indigestion; so costiveness, by occa-
sioning this, is very hurtful to gouty persons. It is there-
fore necessary for such persons to prevent or remove
costiveness, and by a laxative medicine, when needful;
but it is at the same time proper, that the medicine em-
ployed should be such as may keep the belly regular,
without much purging. Atactics, rhubarb, magnesia

roxysm, but in a few others it lias produced alarming effects, such as syn-
cope, cold sweats, extreme prostration of strength, excessive evacuations
from the stomach and bowels, accompanied by a pulse scarcely perceptible,
and a degree of insensibility that indicated approaching dissolution. Such
consequences, however, have only ensued when an improper dose of the
nostrum has been taken. Besides possessing the properties of an emetic
and a cathartic, it appears also to be endowed with the properties of a nar-
cotic, as in some instances it seems to act as an anodyne, previous to any
sensible evacuation taking place."

The Eau Medicinale is a vegetable preparation, of a bitter and nauseous
taste, the composition of which remains a secret. Some suppose it to con-
sist of white hellebore, others of gratiola or hedge-hyssop, a third class of
the colchicum autumnale, or meadow saffron, and a fourth of the roots of*
betony, infused in Spanish white wine, with the addition of tincture of
opium.

The experience of American physicians in the use of this nostrum is not
very ample. As far, however, as it has extended, it has, we believe, tended
somewhat to confirm the favourable opinion originally entertained of its anti-
arthritic qualities.

In the dose of from half a drachm to two drachms, taken in any conve-
nient vehicle, it greatly mitigates the pain, and shortens the duration of the
paroxysm, after it has occurred ; while, in doses of from ten drops to a scru-
ple or half a drachm, it is found to prevent it, after the premonitions of its
approach have been felt.

We have no evidence of its being calculated to remove entirely the pre-
disposition to gout; nor any of its tendency to produce on the stomach
those deleterious effects which follow the use of Portland Powder.

But, if it continue uniformly to relieve the pain and to protract the inter-
vals of the paroxysms of gout, it cannot be otherwise regarded than as an
important remedy.

We regret to find that, in Great Britain, it does not altogether maintain
its original character.

In atonic gout, the pulvis sabins, in moderate doses, is a ttsefhl remedy.
VOL. t. X X

J46 PRACTICE OF PHYSIC.

alba, or flowers of sulphur, may be employed, as the one
or the other may happen to be best suited to particular
persons.

559. These are the several measures (from 541. to
558.) to be pursued in the intervals of the paroxysms;
and we are next to mention the measures proper during
the time of them.

560. As during the times of paroxysms the body is
in a feverish state, no irritation should then be added
to it; and every part, therefore, of the antiphlogistic re-
gimen, (130. to 133.) except the application of cold,
ought to be strictly observed.

Another exception to the general rule may occur
when the tone of the stomach is weak, and when the
patient has been before much accustomed to the use of
strong drink; for it then may be allowable, and even ne-
cessary, to give some animal food, and a little wine*

* We have never seen a case of regular gout accompanied with fever,
in which the exhibition of either wine or animal food was admissible. Al-
though we do not believe in the unity of disease, yet, practically speaking,
inflammatory fever, whatever may be its name, is so far an unit, as to be
always increased by the operation of stimulants. But the fever of real po-
dagra is known to be inflammatory: it does not, therefore, admit of the ex-
hibition of wine or animal food.

If the form of gout be atonic; or the topical affection threaten to recede
from the foot, and attack the stomach ; in either case, wine and other stimu-
lants become essential. But in true podagra, when the pain is severe and
the fever considerable, the action of the system should be diminished, not
increased. We are convinced that the amount of suffering in regular gout
is greatly augmented by the injudicious manner in which that complaint is
generally treated — we ought rather to say, the actual neglect with which it is
treated.

On this subject, we can do nothing else so well calculated to instruct our
readers, as to quote, from his manuscript lectures, the sentiments of our
very able and distinguished friend, the present Professor of the Theory and
Practice of Physic, in the University of Pennsylvania.

" It may be proper for me in this place, (says the Professor,) to state, that
the treatment of podagra or regular gout, by active purging, is a very ancient
practice. It indeed prevailed, with no interruption, from the earliest times,
until it was prohibited by Sydenham, on purely theoretical views: it being,
he observes, ' an inviolable law of nature, that the matter of the disease

PRACTICE OF PHYSIC. 347

^61. That no irritation is to be added to the system
during the paroxysms of gout, except in the cases men-
tioned, is entirely agreed upon among physicians: But

should be thrown out by the extremities, emetics and cathartics will have
no other effect, than that of bringing back the offending matter to the
bowels.'

" Enslaved by the authority of Sydenham, we have ever since, with some-
very limited exceptions, wholly abandoned the use of purgatives, and have
been most commonly content to let the attack spontaneously exhaust itself.
To envelope the limb with flannel, and to urge a patient endurance of the
pain, constitute, indeed, proverbially, the amount of what is at present done
in a regular paroxysm of gout.

" It appears to me, that the example of Sydenham has been, in this case,
exceedingly mischievous ; having led, in my opinion, to the desertion of a
practice, which, if judiciously applied, is not only safe, but peculiarly calcu-
lated to overcome this most distressing disease.

" It would ill comport with my duties, were I to indulge in any minute, or
lengthened disquisition respecting the nature and causes of gout. My im-
pression, very concisely stated, is, that this disease, if not originating in, has
a most intimate connection with, certain states of the alimentary canal. I am
inclined to this view of the subject, from having so frequently observed gout
to commence with the symptoms which denote a disordered condition of
the stomach and bowels. The precursory indications of an approaching at-
tack of this disease are, almost invariably, flatulence, sour eructations, indi-
gestion, depraved appetite, nausea, strong sensations of internal heat, and
obstinate constipation, or a lax and disordered state of the bowels. —

— "But whether the opinion I have ventured to advance on this subject
be right or wrong, (continues the Professor,) it may be confidently stated,
that the practice it dictates is perfectly sound, and fully warranted by long
and diversified experience.

" I have now, for several years, habitually employed purgatives in the
paroxysms of gout, and with unequivocal advantage. Wot content with
simply opening' the bowels, I completely evacuate, by active purging, the
entire alimentary canal. This being accomplished, all the distressing sen-
sations of the stomach which I have mentioned are removed, the pain and
inflammation of the limb gradually subside, and the paroxysm, thus broken,
speedily passes away. To effect these purposes, however, it is often neces-
sary to recur to the remedy repeatedly.

" Though, in some instances, the operation of a single cathartic will be
productive of considerable relief, it more generally requires successive purg-
ing for several days to do it.

" My practice has been, to administer every day, or every other day, a
very large dose of rhubarb and magnesia, to produce a greater or lesser
number of openings, according to the strength of the patient, and the vio-
lence of the case."

This statement of his own practice in regular gout, the Professor proceeds
to corroborate by an account of that of other distinguished physicians cf

348 PRACTICE OF PHYSIC

it is a more difficult matter to determine whether, during
the time of paroxysms, any measure may be pursued
to moderate the violence of reaction and of inflamma-
tion. Dr. Sydenham has given it as his opinion, that the
more violent the inflammation and pain, the paroxysms
will be the shorter, as well as the interval between
the present and next paroxysm longer; and, if this
opinion be admitted as just, it will forbid the use of any
remedies which migiit moderate the inflammation ; which
is, to a certain degree, undoubtedly necessary for the
health of the body. On the other hand, acute pain
presses for relief; and, although a certain degree of in-
flammation may seem absolutely necessary, it is not cer-
tain but that a moderate degree of it may answer the
purpose: And it is even probable that, in many cases,
the violence of inflammation may weaken the tone of
the parts, and thereby invite a return of paroxysms. It
seems to me to be in this way, that, as the disease ad-
vances, the paroxysms become more frequent.

562. From these last considerations, it seems pro-
bable, that, during the time of paroxysms, some mea-
sures may be taken to moderate the violence of the in-
flammation and pain; and particularly, that in first pa-
roxysms, and in the young and vigorous, blood-letting
at the arm may be practised with advantage. But I am
persuaded that this practice cannot be repeated often
with safety; because blood-letting not only weakens the

former times and distant countries. Indulging himself, here, in a rapid
gLnce over the annals of medicine, he clearly shows, that from the time of
Hippocrates to that of Sydenham, podagra was uniformly treated hy active
purging : and further, that although the latter character, from the peculiarity
of his views, and by the weight of his authority, rendered this mode of prac-
tice somewhat unpopular it was, notwithstanding, pursued, until a much
later period, hy some of the most eminent physicians of Europe.

We regret exceedingly that our limits do not permit us to quote the whole
of the Professor'* remarks and illustration's touching this subject, as they
could not fail to prove highly interesting and instructive to our readers

PRACTICE OF PHYSIC. 349

tone of the system, but may also contribute to produce
plethora. I believe, however, that bleeding by leeches on
the foot, and upon the inflamed part, may be practised,
and repeated with greater safety ; and I have known in-
stances of its having been practised with safety, to mo-
derate and shorten paroxysms; but how far it may be
carried, we have not had experience enough to deter-
mine.

563. Besides blood-letting, and the antiphlogistic re-
gimen, it has been proposed to employ remedies for
moderating the inflammatory spasm of the part affected,
such as warm bathing and emollient poultices. These
have sometimes been employed with advantage and
safety; but, at other times, have been found to give oc-
casion to a retrocession of the gout.

564. Blistering is a very effectual means of relieving
and discussing a paroxysm of the gout ; but has also
frequently had the effect of rendering it retrocedent*

565. The stinging with nettles 1 consider as analogous
to blistering; and I think it probable that it would be
attended with the same danger.

566. The burning with moxa, or other substances, I
consider as a remedy of the same kind. I have had indeed
no evidence of this proving hurtful; but neither have I
had any proper evidence of its having proved a radical
cure.

567. Camphire, and some aromatic oils, have the
power of allaying the pain, and of removing the inflam-
mation from the part affected; but these remedies com-
monly make the inflammation only shift from one part

* In case of the retrocession of gout, blisters and sinapisms are useful
remedies in recalling tlie topical affection to the extremities. But blister-
ing the pari where the affection is already situated, with a view to its dis-
cussion, is a practice, which, we believe, is very rarely pursued. We have
never seen an instance of it, nor can we discover any correctness of principle
on which it is founded.

350 PRACTICE OF PHYSIC.

to another, and therefore with the hazard of its falling
upon a part where it may be more dangerous: and they
have sometimes rendered the gout retrocedent.

568. From these reflections (563. et seq.) it will ap-
pear that some danger must attend every external ap-
plication to the parts affected during a paroxysm; and
that therefore the common practice of committing the
person to patience and flannel alone, is established upon
the best foundation.*

569. Opiates give the most certain relief from pain;
but, when given in the beginning of gouty paroxysms,
occasion these to return with greater violence. When,
however, the paroxysms shall have abated in their vio-
lence, but still continue to return, so as to occasion
painful and restless nights, opiates may then be given
with safety and advantage, .especially in the case of per-
sons advanced in life, and who have been often affected
with the disease.

570. When, after paroxysms have ceased, some swell-
ing and stiffness shall remain in the joints, these symp-
toms are to be discussed by the diligent use of the
flesh-brush.

571. Purging, immediately after a paroxysm, will be
always employed with the hazard of bringing it on
again, f

572. I have now finished what has occurred to be
said upon the means of preventing and curing the regu-

* As far as our own observation has enabled us to decide, we consider all
active topical applications, in cases of podagra, somewhat hazardous; and are,
therefore, inclined to caution practitioners against their use We believe,
with our author, that soft flannel, or flakes of carded wool, or cotton, consti-
tute the best remedies of this description. In atonic gout, the same objec-
tions against topical applications do not exist. In that complaint, when in the
form of lumbago, sciatica, or pains in the joints, blisters, sinapisms, and
other external irritating means, judiciously directed, are exceedingly useful.

f This we believe to be an error. We have never witm-ssi-d the event
in practice ; nor do we know of any principle on which it could be explained.

PRACTICE OF PHYSIC. 35}

lar gout; and shall now consider its management when
it has become irregular; of which, as I have observed
above, there are three different cases.

573. In the first case, which I have named the Ato-
nic Gout, the cure is to be accomplished by carefully
avoiding all debilitating causes; and by employing, at
the same time, the means of strengthening the system
in general, and the stomach in particular.

574. For the avoiding debilitating causes, I must re-
fer to the doctrines of the Hygieine, as in 553.

575. For strengthening the system in general, I must
recommend frequent exercise on horseback, and mode-
rate walking. Cold bathing also may answer the pur-
pose, and may be safely employed if it appear to be pow r
erful in stimulating the system, and be not applied when
the extremities are threatened with any pain.

For supporting the tone of the system in general,
when threatened with atonic gout, some animal food
ought to be employed, and the more acescent vegeta-
bles ought to be avoided. In the same case, some wine
also may be necessary, but it should be in moderate
quantity, and of the least acescent kinds; and, if every
kind of wine shall be found to increase the acidity of
the stomach, ardent spirits and water must be em-
ployed.*

576. For strengthening the stomach, bitters and the
Peruvian bark may be employed; but care must be
taken that they be not constantly employed for any great
length of time. Compare 556.

The most effectual medicine for strengthening the
stomach is iron, which may be employed under various

* Persons subject to atonic gout should approach the cold bath with great
caut.on. If, on being used, it excite on the surface of the body and extreme
ties, a pleasant glow, it may be safely continued; but, if it produce a sensa-
tion of chilliness, let it be promptly abandoned.

352 PRACTICE OF PHYSIC.

preparations ; but, to me, the best appears to be the rust
in fine powder, which may be given in very large doses.

For supporting the tone of the stomach, aromatics
may be employed; but should be used with caution, as
the frequent and large use of them may have an oppo-
site effect; and they should therefore be given only in
compliance with former habits, or for palliating present
symptoms.

When the stomach happens to be liable to indiges-
tion, gentle vomits may be frequently given; and proper
laxatives should be always employed to obviate, or to
remove costiveness.*

577. In the atonic gout, or in persons liable to it, to
guard against cold is especially necessary; and the most
certain means of doing this is, by repairing to a warm
climate during the winter season.

578. In the more violent cases of the atonic gout,
blistering the lower extremities may be useful; but that
remedy should be avoided when any pain threatens the
extremities. In persons liable to the atonic gout, issues
may be established in the extremities, as, in some mea-
sure, a supplement to the disease. f

579. A second case of the irregular gout, is that
which I have named the Retrocedent When this af-
fects the stomach and intestines, relief is to be instantly

* Besides acting - with superior efficacy, prepared steel is much less apt to
disorder the stomach, if it be combined witli a small quantity of powdered
ginger, cinnamon, cloves, or some other warm and pleasant aromatic. Of
prepared steel, ten grains may be administered from three to six times a-dny,
according to the exigency of the case, and the retentive power of the
stomach.

Suitable purges for arthritic patients are, magnesia, rhubarb, gum guaia-
cum, or an infusion of senna, rendered aromatic by cardamum, or fennel
seeds.

-j- In Cases of this description, the application of sinapisms is greatly pre-
ferable to that of blisters. The establishment of issues in the extremities,
we consider a hazardous experiment, as the consequence may be, the pro
duction of troublesome sores.

PRACTICE OF PHYSIC. 353

attempted by the free use of strong wines, joined with
aromatics, and given warm; or if these should not prove
powerful enough, ardent spirits must be employed, and
are to be given in a large dose. In moderate attacks,
ardent spirits, impregnated with garlic, or with asafce-
tida, may be employed; or, even without the ardent
spirits, a solution of asafcetida with the volatile alkali
maj answer the purpose. Opiates are often an effec-
tual remedy, and may be joined with aromatics, as in
the Electuarium Thebaicum; or they may be usefully
joined with volatile alkali and camphire. Musk has
Jikevvise proved useful in this disease,

When the affection of the stomach is accompanied
with vomiting, this may be encouraged, by taking
draughts of warm wine, at first with water, and after-
wards without it; having at length recourse, if necessary,
to some of the remedies above-mentioned, and particu-
larly to the opiates.

In like manner, if the intestines be affected with diar-
rhoea, this is to be at first encouraged, by taking plenti-
fully of weak broth; and when this shall have been done
sufficiently, the tumult is to be quieted by opiates.*

580. When the retrocedent gout shall affect the lungs,
and produce asthma, this is to be cured by opiates, by
antispasmodics, and perhaps, by blistering on the breast
or back.f

* In a case like this, opiates may be given in very powerful and repeated
doses An ounce of laudanum has been administered in the space of eight
hours, w'nh safely and success. If the spasm be violent, eiiher may be, ex-
hibited with particular advantage. So may a very strong tincture of assafce-
tid i, jarlic or camphor.

We know not on what principle wine should be given to promote vomit-
ing in retrocedent gout Warm water is greatly preferable.

fin the treatment of this form of retrocedent goin, emetics are exhibited
with the happiest effect. Cupping on the breast, or along the spine oppo-
site to the thorax, is also useful Our author is correct in his opinion of
blistering. It constitutes, here, an important remedy. So do stimulating
applications to the extremities.

VOL, I.

yy

354 PRACTICE OF PHYSIC.

581. When the gout, leaving the extremities, shall
affect the head, and produce pain, vertigo, apoplexy,
or palsy, our resources are very precarious. The most
probable means of relief is, blistering the head: and if
the gout shall have receded entirely from the extremi-
ties, blisters may be applied to these also. Together
with these blisterings, aromatics, and the volatile alkali,
may be thrown into the stomach.*

582. The third case of the irregular gout is what I
have named the Misplaced; that is, when the inflamma-
tory affection of the gout, instead of falling upon the
extremities, falls upon some internal part. In this case,
the disease is to be treated by blood-letting, and by
such other remedies as would be proper in an idiopa-
thic inflammation of the same parts.

583. Whether the translation so frequently made
from the extremities to the kidneys, is to be consider-
ed as an instance of the misplaced gout, seems, as we
have said before, uncertain; but I am disposed to think
it something different; and therefore am of opinion,
that, in the Nephralgia Calculosa produced upon this
occasion, the remedies of inflammation are to be em-
ployed no farther than they may be otherwise some-
times necessary in that disease, arising from other
causes than the gout.

• In this form of the disease, copious purging, with the application of
cups to the temples, and also venesection, if the system will hear it, are re-
medies of fair promise, and ought not to be omitted. The application of
blisters to the ankles, and sinapisms to the feet, may also be practised with
the prospect of advantage. In every case of gout, whether atonic or retro-
cedent, it is correct practice to endeavour, by irritating applications, to fix
it in the extremities— the hands or feet, according to its tendencies.

PRACTICE OF PHYSIC. S5n

BOOK III.

OF EXANTHEMATA,

OR ERUPTIVE FEVERS

584. THE diseases comprehended under this title,
which make the third Order of Pyrexias in our Noso-
logy, are In general such as do not arise but upon oc-
casion of a specific contagion applied, which first pro-
duces fever, and afterwards an eruption upon the sur-
face of the body; and which diseases, for the most part,
affect persons but once in the course of their lives.*

5S5. Whether the character of the Order may be
thus limited, or if the Order may be allowed to com-
prehend also the eruptive fevers produced by a matter
generated in the body itself, and likewise those cases
of eruption which do not depend upon contagion, or
upon a matter generated before the fever, but upon a

* We shall, hereafter, say more particularly, that Pestis vera, or true
Plague, is very improperly referred to the order exanthemata. It is not an
eruptive disease; but belongs, of right, to the order febres ; or rather, per-
haps, to that of phlegmasia; in as much as it is usually marked by some in-
flammatory affection, particularly an inflammation of the stomach. The hu-
man body, moreover, is liable to be attacked by it more than once. We do
not believe that either it or scarlet fever is, strictly speaking, a contagious
disease.

We feel persuaded, that all the exanthemata are original diseases of the
stomach : we mean, that they originate in a topical affection of that organ.

Having never seen a case of oriental plague, we no not feel authorized to
speak of the treatment of that disease.

356 PRACTICE OF PHYSIC,

matter generated in the course of ihc fever, 1 am not
ready to determine. Of the diseases enumerated by
the Nomologists as Exanthemata, there are certainly
three different kinds, which may be distinguished by
the circumstances mentioned in this and the preceding
paragraph. Of the first kind are the Small-Pox, the
Chicken-Pox, the Measles, the Scarlet Fever, and the
Plague. Of the second kind seems to be the Erysipe-
las; and of the third kind I judge the Miliaria and Pe-
techia to be. But as I am not sufficiently confident in
the facts which should support these distinctions, or
which would enable us to apply them in all cases, I go
on in this book to treat of almost all the exanthemata
enumerated by preceding Nosologists, with only some
difference in the arrangement from what it was in my
former editions.

CHArTER t.
OF THE SMALL POX.*

586. THE small pox is a disease arising from a con-
tagion of a specific nature, which first produces a fever;

* For manv years past, the attention of physicians, both in Europe and
America, has been directed, not to the making 1 of improvements in the treat*
ment of casual small-pox, but, first, to the mitigation of that disease by the
practice of inoculation ; and, ultimately, to its entire prevention, by substi-
tuting' in its place, the variolae vaccina;, or cow-pox.

As we hope, that even inoculation will never hereafter be practised in
anv part of the world, we should deem it superfluous to engross the time
of our readers by any particular directions respecting it — much less do we
think it our duty to trouble them with additions to what our author has said
on the subject of the casual, or, as it is usually denominated, the natural
small-pox. Instead of this, it will be much more useful, as we conceive, and
will certainly better accord with the present state of medicine, to invite
their attention to an account of the cow-pox. This we shall do, in the shape

PRACTICE OF PHYSIC. 357

and on the third or. fourth day thereof, produces an
eruption of small red pimples. These are afterwards

of a note, as it would be wrong to interpolate, in any way, the text of our
author.

On looking over the article "Vauiolb Yaccix.e, on Cow-Pox," in Tho-
mas's " Modern Practice of Physic," we find it to be sensible and well com-
posed — much compressed, indeed, yet containing almost everything neces-
sary to be known in relation to that disease. We shall, therefore, insert it
here, precisely as it stands, prefacing it with the following brief remarks.

Our own experience in relation to the comparative force of the poisons
of small. pnx and cow-pox, is somewhat different from that of Dr. Thomas.

Soon after the introduction of the latter disease into the city of Philadel-
phia, we inserted those two poisons into the different arms of the same in-
dividual — a boy about twelve years old. The experiment with each virus
succeeded so far as to produce a topical affection ; and the two affections in-
creased, pari passu, until about the eighth day. At this period, however, a
very striking difference ensued. The vaccine pock assumed completely its
characteristic appearance, and took possession of the system in the form of
a general disease ; while the variolous pock ceased to make any further
progress in growth, and, in a few days, withered and disappeared, without
suppurating, or producing the slightest affection of the system.

This is the only experiment we made Circumstances, at the time, pre-
vented us from repeating it ; and the efficacy of the vaccine, as a preventive
of the variolous disease, being - soon afterwards established to our satisfac-
tion, we did not feel it necessary to return to the subject.

It is found in this country, and the fact is now, we believe, known and ac-
knowledged in Europe, that the virus of the cow-pox can be preserved with
more certainty, for a much longer time, and in better condition, in a dry
than in a humid state. We vaccinate, therefore, with the scab, when per-
fectly desiccated, rather than with the matter taken from the pock in a fluid
form. Thus fixed and secured from the effects of both fermentation and
evaporation, the virus may be conveyed to almost any distance, and the dis-
ease propagated in the remotest parts of the world.

A scab, with the cuticle entire, small, perfectly circular, of a dark maho-
gany colour, and somewhat rough on the external surface, is found to be
most richly imbued with the poison, and to retain it longest in an active con-
dition.

Unless in cases where it has been improperly irritated, by accident, or in-
tentional scratching, the affection of the arm, in the cow-pox, has never
provecr%i the slightest degree troublesome to us.

This disease may be propagated with equal advantage at every season of
the year, except that, during the severities of winter, and the intense heats
of summer, when the skin is strongly stimulated by heat and cold, it cannot
he communicated with the same facility as during the milder weather of the
autumn and spring.

It is often stated, as a question, why an inoculated disease is less severe

358 PRACTICE OF PHYSIC.

formed into pustules, containing a matter, which, in the
course of eight days from the time of the eruption, is

than cne contracted casually ? or, as it is usually expressed, in the natural
way ? \

To us, the answer has always appeared to be plain and easy.

The strength and severity of a disease are proportioned to the importance
and the sympathies of the organ in which it has its seat. On this account,
diseases that are sealed in the stomach, are more violent than those which
are radicated in the skin. This, we consider, as amounting to a solution of
the question we are considering.

An inoculated disease — small-pox, for example — has its origin in the skin,
and affects the stomach secondarily and slightly: but the casual small-pox
takes root in the stomach, and produces in that organ a much more power-
ful and serious affection. Hence the violence and danger of the disease
that follows.

Thus, the passage of a ball or a bayonet through the muscles of the
thigh, gives rise, to a wound which is rarely fatal ; while the same weapon, by
passing through the stomach or the intestines, produces a disease which is
seldom cured.

VARIOUE VACCINA, Oil COW-POX.

In many of the dairy counties it has been long known that the cows are
liable to an eruption on their paps or udders, which was occasionally com-
municated to the hands or arms of those who milked them, producing an
ulcer, and some degree of fever; and it had been observed by the people of
those counties, that those who had undergone this disease, known by the
name of cow-pox, were not liable to the small-pox.

The disease had not, however, undergone any medical investigation until
l)r. Jenner, then of Berkley, in Gloucestershire, paid particular attention to
it. He very satisfactorily ascertained that it was a much milder disease than
the small-pox, and that the fact was true, that it secured those who had been
infected with it from afterwards being liable to variolous infection. He also
observed that the vaccine-pox is not infectious, but by inoculation ; and that
on this account it might be inoculated in a family without endangering
others; a circumstance of the greatest importance. On the suggestions of
Dr. Jenner, many practitioners were induced to adopt the practice of sub-
stituting the one disease for the other, and its efficacy is now fully esta-
blished.

With respect to the origin of the disease in the cow, we are informed by
Dr. Jenner, that he traced it to the diseased heels of horses which had been
affected with the grease ; and by the person appointed to apply the dress-
ings to them, not paying a due attention to cleanliness, and incautiously bear-
ing his part in milking the cows, with some particles of the infectious mat-
ter adhering to his fingers, he has communicated the disease to them. From
numerous experiments made, however, at an early period, by the late Dr.
Woodville, and by Mr. Coleman, Professor at the Veterinary College, with

PRACTICE OF PHYSIC. 359

changed into pus. After this, the matter dries, and falls
off in crusts.

the matter of grease, taken in the various stages of that complaint, no such
effect has been produced upon cows. Neither were inoculations with this
matter, nor with several other morbid secretions in the horse, productive of
any effects upon the human subject, which by no means accord with the
tacts adduced by Dr. Jenner on this point.

Some communications through the medium of the Medical and Physical
Journal (see vol. iv. pages 381 and 466,) in consequence of still later expe-
riments, seem however to give support to Dr. Jenner's opinion as to the
origin of the disease.

On its first investigation, some circumstances led to the supposition that
the cow-pox and the small-pox were originally one and the same disease;
the latter being derived from the animal at some remote period, and having
undergone in the lapse of years, and by the influence of various constitu-
tions, the changes we now experience. Subsequent facts have, however,
invalidated this opinion.

From various experiments it appears that the vaccine disease and the
small-pox are not susceptible of intermixture, but that each preserves its
distinct character under all circumstances. At the Small-pox Hospital it
has been noticed, that when the vaccine and variolous fluids are mixed to-
gether, and thus inserted, sometimes the vaccine pustule, at others the vari-
olous, has been produced, each of them retaining its characteristic marks
throughout. Again, it has been found, that when the two fluids are insert-
ed separately, and so near together, that the two pustules which follow
spread into one, by inoculating with the fluid taken from one side of it, the
vaccine pustule alone will be produced, while the fluid taken from the other
excites the genuine variolous pustule, with the general eruption of small-
pox on the body. Another point of dissimilarity between the variolous and
vaccine diseases is this : the inoculation of the former we well know super-
sedes the natural disease many days after exposure to infection.

The effect produced by submitting persons to the influence of* variolous
and vaccine matter at the same time, is, that they both prove effective ; for
the vaccine vesicle proceeds to its acme in the usual number of days, and
the maturation of the variolous pustules is attended with a pustular eruption
on different parts of the body ; but when variolous matter is not inserted
untd the ninth day after the inoculation with vaccine matter, the action of
the variolous seems to be wholly precluded.

The variolous and vaccine fluids inoculated about the same time, restrain
the action of each other. The vaccine vesicle, in this case, is smaller, and
proceeds more slowly to its maturity; and the variolous pustules are small,
hard, and shining, producing only a small particle of matter at their apices.
The nipples of the cow being once affected, the disorder is communi-
cated to the dairy -maids, and other assistants employed in milking, and by
them it is spread through the farm, till at last most of the cattle experience
its consequences.

360 PRACTICE OF PHYSIC.

587. This is a general idea of the disease: hut there
are two particular forms or varieties of it, well known

The disease appears on the nipples of the cows in the form of irregular
pustules, which on their first appearance are commonly of a colour some-
what approaching to livid, and are surrounded by an erysipelatous inflam-
mation, according to the report of Dr. Jenner; but Dr. Woudville seems to
think that it is rather an indurated tumefaction of the skin which surrounds
the pustules, than an inflammation of an erysipelatous nature. Unless pro-
per remedies are applied in time, these pustules soon degenerate into pha-
gedenic ulcers, which prove extremely troublesome ; the animals then be-
come much indisposed, and the secretion of milk suffers a considerable di-
minution.

Inflamed spots now begin to appear on different parts of the hands and
wrists of the domestics employed in milking, which run on quickly to sup-
puration, assuming at first the appearance of small vesications produced by
a burn. Most commonly they come out about the joints of the fingers, and
at their extremities; but whatever parts are affected, if the situation will
admit, these superficial suppurations put on a circular form, with their edges
more elevated than their centre-, and of a colour distinctly approaching to
blue In consequence of absorption, tumours appear in each axdla, the
system becomes affected, the pulse is quickened, and rigours, with general
lassitude and pains about the limbs and loins, with a vomiting, come on. In
some instances, the head is much affected, and a delirium arises.

These symptoms varying in their degrees of violence, usually continue
for three or four days, leaving ulcerated sores about the hands, which from
the sensibility of the parts are very troublesome, and commonly h^al slowly,
becoming not unfrequently phagedenic, like those from which they sprung.

The lips, nostrils, eye-lids, and other parts of the body, are likewise af-
fected sometimes with sores, in consequence of being heedlessly rubbed or
scratched with the patient's infected fingers.

Dr. Jenner informs us that he had never met with any case of the cow-
pox, either taken naturally, or produced artificially, which proved fatal ; but
by Dr. Woodville we are told, that out of five hundred cases of inoculated
cow-pox under his care, one proved fatal, which was a child at the breast,
on the eleventh day after the matter had been inserted in the arm

From that occurrence, and a few cases in which the febrile symptoms ran
high, this gentleman was at first very adverse to the vaccine inoculation ; but
from further trials he latterly gave it, with almost every other practitioner,
the most decided preference.

The few instances of death which have occurred from vaccine inoculation,
since it has been more generally practised, may probably be referred with
much justice to some unknown peculiarities of the constitution ; to inter-
vening disorders independent of the vaccine, and to inflammation excited
by accidental causes in young children, especially when they have been ill
fed and badly nursed — circumstances not uncommon among very poor
people.

"When the pustules are numerous, as sometimes happens where the dis-

PRACTICE OF PHYSIC. 361

under the appellations of the Distinct and Confluent,
which require to be specially described.

ease has been received immediately from the cow, a considerable degree of
fever attends ; bnt when it has arisen from inoculation, few or no pustules
are to be observed, except immediately round the wound in the arm ; and
little or no inconvenience is experienced.

A more general knowledge of the disease, than what we had at first, has
ascertained it to be an undoubted fact, that the vaccine virus is greatly mo-
dified, and rendered much milder by passing through different habits; and
that although the cow-pox has proved in many instances a severe disorder
in those who received the infection immediately from the animal, still, in a
few instances only, have the' symptoms run high, or has the least inconve-
nience been experienced, where proper matter taken from the human sub-
ject was used for inoculation.

in the few cases which have been brought forward, where a numerous
eruption, proceeded by a fiery redness, took place, we should attribute it
to something wrong in the habit of body ; to the intervening of some other
eruptive disease ; or possibly to the having inoculated with matter which
had undergone a decomposition, in consequence of putrefaction, or some
other cause not obvious.

A use of medicine seems wholly unnecessary in the cow-pox, except in
those cases of the natural disease where much febrile heat attends; and
then the antiphlogistic plan ought to be pursued.

The vaccine virus is certainly of a very singular nature, in as much as that
a person who has been infected by it, is found to be for ever after secure
from the infection of the small-pox ; neither exposure to variolous effluvia,
nor the insertion of the matter into the skin, being capable of producing
the disease. Many direct experiments made by innumerable practitioners,
prove that the susceptibility of the small-pox is totally destroyed by inocu-
lating with the vaccine matter. The permanency of the effect was indeed
a matter of some doubt, but that is now fully established. It appears from
the report of the Small-pox Hospital in London, that up to December 1802,
eleven thousand eight hundred patients and upwards had been vaccinated,
of which number twenty-five hundred were afterwards proved to be secured
from the natural small-pox, by receiving a further inoculation with small-pox
matter, while they were at the same time exposed in an hospital full of its
infection, without effect. It was said at first, that although the cow-pox de-
stroyed the susceptibility of the small-pox, still it possessed not the same
power with regard to itself, as a person might have the disease more than
once. Instances certainly have been adduced of the cow-pox taking place
a second time ; but they are of very rare occurrence, and should be looked
on as irregular. The same has happened with the small-pox.

In Dr. Jenner's first treatise, he mentions that the small pox is not always
a security against the cow-pox, and that although the susceptibility of the
virus of the cow-pox is for the most part lost in those who have had the
VOL. I. Z Z

362 PRACTICE OF PHYSK

588. In the former, or in the distinct small-pox, the
eruptive fever is moderate, and appears to be evidently

small-pox, yet in some constitutions it is only partially destroyed, and in
others it does not appear to be in the least diminished. A more intimatt
knowledge of the disease has convinced us of the fallacy of this opinion.

Soon after Dr. Jenner's first publication on the vaccine disease, a few in-
stances were adduced, tending to invalidate his supposition of the preven-
tive power of the cow-pox with regard to variolous infection ; but these he
considers to have been cases of a spurious disease, and therefore not affect-
ing his general conclusion.

In using this term, he does not mean, however, to imply that there is a
true and false cow-pox, but merely to express an irregularity or difference
from that common form and progress of the vaccine pustule from which its
efficacy is inferred. Those who perform vaccination ought, therefore, to be
■well instructed, and should have watched with the greatest care the regular
process of the pustule, and learned the most proper time for taking the
matter.

A few cases of still later occurrence have also been brought forward by
Mr. Goldson* of Portsmouth, and others, with a view of proving that the in-
oculated cow-pox is not a permanent security against the infection of the
small-pox ; but a failure in one or two cases out of more than thirty thousand,
although ever so well substantiated, should be considered in no other light
than as a casual irregularity, upon which no solid determination can, or
ought to be grounded. Instances of the like nature have been known to
occur likewise among persons inoculated with variolous matter, and when
they are met with, ought to be looked on as anomalous.

There can be little doubt, however, that some of the failures are to be
imputed to the inexperience of the early vaccinators, and it is by no means
unreasonable to expect that further observation will yet suggest many im-
provements that will reduce the number of anomalous cases, and furnish the
means of determining with greater precision when the vaccine disease has
been effectually received.

Persons who have been vaccinated, and passed through the cow-pox with
all the usual accompanying symptoms, and who have afterwards taken the
small-pox, of which a very few instances may have happened, have generally
imperfect pustules, which die away, in a few days, without exciting any con-
stitutional complaint; but the matter taken from these pustules will com-
municate the small-pox. This circumstance has been brought forward by
the anti-vaccinists as a proof that persons who have had the cow-pox, may
afterwards take the small-pox by inoculation, and otherwise, not making
the proper distinction between local and constitutional infection; or per-
haps not understanding how any one can communicate a disease to others,
with which he is not himself infected.

* See his cases of Small-pox subsequent to Vaccination.

PRACTICE OF PHYSIC. 363

of the inflammatory kind, or what we name a Synocha.
It generally comes on about mid-day, with some symp-

We are informed by Dr. Jenner that the sources of a spurious cow-pock
are as follow :

1st, That arising from pustules on the nipples ov udder of the cow ;
which pustules contain no specific virus.

2dly, From the matter (although originally possessing the specific virus)
which has suffered a decomposition either from putrefaction, or from any
other cause less obvious to the senses.

odly, When the matter is taken from an ulcer in an advanced stage, which
ulcer arose from a true cow-pock : and,

4thly, He supposes a spurious disease to arise from matter produced on
the human skin, from contact with some peculiar morbid matter generated
by a horse.

The characteristics of the true cow-pox are as follow, viz a circumscribed,
circular, elevated eruption, surrounded by a red halo or efflorescence,
smooth surface ; brown, black, or mahogany, and tamarind-stone coloured,
long adhering scab.

From a chemical analysis of vaccine matter by some French physicians, it
was found to consist of water and albumen.

The succeeding arguments have been urged in favour of inoculation for
the cow-pock over that for the small-pox.

1st, Of several thousand persons who have had the inoculated cow-pock,
only one or two have died.

2dly, Very few well attested instances have been produced out-of many
thousands of the above persons, known to have had the inoculated vaccine
pock, and who were subsequently inoculated for the small-pox, of this dis-
ease being afterwards taken ; although many of these were also exposed to
the infectious effluvia of the natural small-pox. And, traditionally, this fact
has been established time immemorial, with regard to the casual cow-pox.

odly, It may safely be affirmed, that the inoculated cow-pock is generally
a much slighter disease than the inoculated smallpox ; and that the propoi-
tion of severe cases in the latter is to the former as at least ten to one.

4thly, It does not appear that the genuine vaccine pock can be propagated
like the small-pox, by effluvia from persons labouring under it. Hence, if
the vaccine inoculation should be universally instituted in place of the small-
pox, it is reasonable to conclude, that this most loathsome and fatal malady
will be extinguished.

5thly, It does not appear that the vaccine poison, like that of the small-po.x,
can be conveyed so as to produce the, disease indirectly from diseased per-
sons, by adhering to clothes, furniture, bedding, letters, &c. Hence, no
danger of its propagation in these channels is to be apprehended from the
universal practice of the inoculation of the cow-pock.

6thly, It has been found, that a person whose constitution has distinctly
undergone the vaccine disease, is in future unsusceptible of the same dis-
order. Hence no objection can be made to the new inoculation, as was
once urged, on account of its being believed, that by the commutation of the

364 PRACTICE OF PHYSIC.

toms of a cold stage, and commonly with a considerable
languor and drowsiness. A hot stage is soon formed,

small pox for the vaccine pock, an eruptive disease would be introduced, to
which the same person would be repeatedly liable.

7thly, It does not appear that those who have already gone through the
small-pox, are susceptible of the vaccine disease as was at first believed.
Hence no objection can be urged on the score of persons who have already
g'me through the small-pox, being liable to a new infectious disease, by the
introduction of the vaccine inoculation.

8 hly, Experience shows, that there is no reason to apprehend the small-
est chance of deformities ol the skin from the vaccine inoculation.

9thly, The extensive practice of the vaccine inoculation, and the accounts
of the disease in the casual way, do not show that any other disease will be
excited subsequently, which is peculiarly imputable to the new practice.

On a review of these arguments founded on facts, there can remain no
doubt but thai the vaccine inoculation will soon wholly supersede and do
away the variolous. Could all parents be persuaded to inoculate their
children with vaccine matter soon after birth, the small-pox might be
entirely eradicated in time. The introduction of this species of inoculation
generally throughout both the army and navy, and its extension to France,
Spain, Germany, and every part of the continent, as well as to both the In-
dies, fully stamp its value and efficacy, and give us reason to hope that it will
shortly be adopted by every nation of the earth with whom we have the
least communication. Vaccination has indeed penetrated to the remotest
corners of the globe, and wherever it has been introduced, the increasing
experience of every 'year has only served to confirm pretty generally a con-
fidence in its efficacy. It has been recommended and adopted by far the
greatest and most respectable part of the profession, every where ; but, by a
few individuals, it has been obstinately opposed through interested motives.

In inoculating for the vaccine disease, we should carefully attend to the
following circumstances.

1st, That the matter should not be taken later than the ninth day of the
disease.

2dly, That the fluid should be perfectly transparent, as it is not to be de-
pended upon, if it has become in any degree opaque.

3dly, That the matter, if not used immediately, should be allowed to dry
gradually and thoroughly before it is laid by for future use.

4thly, That the punctures can scarcely be made too superficial, and on no
account should more than one be made in each arm.

5thly, That attention should be made to repress, as soon as may be, any
excess of inflammation that may happen to arise; and this is best done by
cold and restringent applications.

From the report of the physicians of the Vaccine Pock Institution, it ap-
pears that the matter of a single pustule, being mixed with one quarter of
an ounce measure of warm water, such diluted matter excited as distinct a
vaccine pock by inoculation, as an equal quantity of undiluted matter. A
pock so excited, was not attended with less inflammation, or constitutional

PRACTICE OF PHYSIC. 365

and becomes more considerable on the second and third
days. During this course, children are liable to frequent
startings from their slumbers; and adults, if they arc
kept a-bed, are disposed to much sweating. On the third
day, children are sometimes affected with one or two
epileptic fits. Towards the end of the third day, the
eruption commonly appears, and gradually increases
during the fourth; appearing first upon the face, and
successively on the inferior parts, so as to be completed
over the whole body on the fifth day.

From the third day, the fever abates; and against the
fifth, it entirely ceases. The eruption appears first in
small red spots, hardly eminent, but by degrees rising
into pimples. These are generally upon the face in small
number; but even when more numerous, they are sepa-
rate and distinct from one another. On the fifth, or
sixth day, a small vesicle, containing an almost colour-
less or whey-coloured fluid, appears upon the top of each
pimple. For two days, these vesicles increase in breadth
only, and there is a small hollow pit in their middle; so
that it is only against the eighth day that they are raised
into spheroidical pustules.

These vesicles or pustules, from their first formation,
continue to be surrounded with an exactly circular in-
flamed margin, which, when the pustules are numerous,
diffuses some inflammation over the neighbouring skin,
so as to give somewhat of a damask rose colour to the
spaces between the pustules. As the pustles increase
in size, if they be numerous on the face, against the
eighth day the whole of the face becomes considerably
swelled: and, in particular, the eye-lids are so much
swelled as entirely to shut the eyes.

affection, than that excited by a larger quantity of undiluted matter; which
points out an easy method of inoculating several persons from a single vac-
cine pock— a great conveniency indeed, when the poor to be inoculated at
one time are very numerous.

36G PRACTICE OF PHYSIC.

As the disease thus proceeds, the matter in the pus-
tules becomes by degrees more opaque and white, and
at length of a yellowish colour. On the eleventh day,
the swelling of the face is abated, and the pustules
seem quite full. On the top of each a darker spot ap-
pears; and at this place the pustule, on the eleventh
day, or soon after, is spontaneously broken, and a por-
tion of the matter oozes out: in consequence of which
the pustule is shrivelled, and subsides; while the mat-
ter oozing out dries, and forms a crust upon its sur-
face. Sometimes a little only of the matter oozes out;
and what remains in the pustule becomes thick, and
even hard. After some days, both the crusts and the
hardened pustules fall off, leaving the skin, which they
covered, of a brown red colour; and it is only after
many days that the skin in these places resumes its na-
tural colour. In some cases, where the matter of the
pustules has been more liquid, the crusts formed by it
are later in falling off", and the part they covered suffers
some desquamation, which leaves in it a small pit or
hollow.

This is the course of things on the face; and succes-
sively, the pustules on the rest of the body take the
same. The matter of the pustules, on the arms and
hands, is frequently absorbed; so that, at the height of
the disease, these pustules appear as empty vesicles.
On the tenth and eleventh days, as the swelling of the
face subsides, a swelling arises in the hands and feet;
but which, again, subsides, as the pustules come to ma-
turity.

When the pustules on the face are numerous, some
degree of pyrexia appears on the tenth and eleventh
days, but disappears again after the pustules are fully
ripened; or perhaps remains in a very slight degree till
the pustules on the feet have finished their course. It

PRACTICE OF PHYSIC. 367

is seldom that in the distinct small-pox the fever con-
tinues longer.

When the pustules on the face are numerous, some
uneasiness in the throat, with a hoarseness of the voice,
comes on upon the sixth or seventh day, and a thin li-
quid is poured out from the mouth. These symptoms
increase with the swelling of the face; and the liquids
of the mouth and throat becoming thicker, are more
difficultly thrown out. There is at the same time some
difficulty of swallowing; so that liquids taken in to be
swallowed are frequently rejected, or thrown out by
the nose. But all these affections of the fauces abate
as the swelling of the face subsides.

589. In the other form of small-pox, or what is call-
ed the Confluent, the course of the disease is, in gene-
ral, the same with that we have described; but the
symptoms of every stage are more violent, and several
of the circumstances are different.

In particular, the eruptive fever is more violent.
The pulse is more frequent and more contracted, ap-
proaching to that state of pulse which is found in the
typhus. The coma is more considerable, and there is
frequently a delirium. Vomiting also is a common
symptom, especially at the coming on of the disease.
In very young infants, epileptic fits are sometimes fre-
quent on the first days of the disease, and sometimes
prove fatal before any eruption appears; or they usher
in a very confluent and putrid small-pox.

590. The eruption appears more early on the third
day, and it is frequently preceded or accompanied with
an erysipelatous efflorescence. Sometimes the erup-
tion appears in clusters, like that of the measles. When
the eruption is completed, the pimples are always more
numerous upon the face, and at the same time smaller
and less eminent. After the eruption, the fever suffers

368 PRACTICE OF PHYSIC.

some remission, but never goes off entirely; and after
the fifth or sixth day it again increases, and continues
considerable through the remaining course of" the dis-
ease.

The vesicles formed on the tops of the pimples ap-
pear sooner; and while they increase in breadth, do not
retain a circular, but are every way of an irregular
figure. Many of them run into one another, insomuch,
that very often the face is covered rather with one ve-
sicle than with a number of pustules. The vesicles, so
far as they are any wise separated, do not arise to a
spheroidical form, but remain flat, and sometimes the
whole of the face is of an even surface. When the
pustules are in any measure separated, their circumfer-
ence is not bounded by an inflamed margin, and the
part of the skin that is free from pustules is commonly
pale and flaccid.

The liquor that is in the pustules changes from a
clear to an opaque appearance, and becomes whitish
or brownish, but never acquires the yellow colour and
thick consistence that appear in the distinct small-pox.

591. The swelling of the face which attends the dis-
tinct small-pox, when they are numerous., and almost
then only, always attends the confluent, comes on more
early, and arises to a greater degree; but abates on the
tenth day, and on the eleventh still more. At this time
the pustules or vesicles break, and, shrivelling, pour
out a liquor that is formed into brown or black crusts,
which do not fall off for many days after. Those of
the face, in falling off, leave the parts they cover sub-
ject to a desquamation, which pretty certainly produces
pittings.

On the other parts of the body, the pustules of the
confluent small-pox are more distinct than upon the

PRACTICE OF PHYSIC. 369

face, but never acquire the same maturity and consist-
ence of pus, as in the properly distinct kind.

The salivation, which only sometimes attends the dis-
tinct small-pox, very constantly attends the confluent;
and both the salivation and the affection of the fauces
above mentioned, are, especially in adults, in a higher
degree. In infants, a diarrhoea comes frequently in
place of the salivation.

In the confluent small-pox, there is often a consider-
able putrescency of the fluids, as appears from pete^
chiae, from serous vesicles, under which the skin shows
a disposition to gangrene, and from bloody urine, or
other hcemorrhagy, all which symptoms frequently ac-
company this disease.

In the confluent small-pox, the fever, which had only
suffered a remission from the time of eruption to that
of maturation, is often, at or immediately after this pe-
riod, renewed with considerable violence. This is
what has been called the Secondary Fever; and is, in
different cases, of various duration and event.

592. We have thus endeavoured to describe the va-
rious circumstances of the small-pox; and from the dif-
ference of these circumstances, the event of the dis-
ease may be determined. The whole of the prognosis
may be nearly comprised in the following propositions:

The more exactly the disease retains the form of the
distinct kind, it is the safer; and the more completely
the disease takes the form of the confluent kind, it is
the more dangerous.

It is only when the distinct kind shows a great num-
ber of pustules on the face, or otherwise, by fever or
putrescency, approaches to the circumstances of the
confluent, that it is attended with any danger.

In the confluent small-pox there is always danger;
and this is always more considerable and certain, ac-

VOL. I. % \

,370 PRACTICE OF PHYSIC.

cording as the fever is more violent and permanent,
and especially as the marks and symptoms of putres-
cency are more evident.

When the putrid disposition is very great, the dis-
ease sometimes proves fatal before the eighth day, but,
in most cases, it is on the eleventh that death happens,
and sometimes it is put off till the fourteenth or seven-
teenth day.

Though the small-pox should not be immediately fa-
tal, the more violent kinds are often followed by a mor-
bid state of the body, of various kind and event. These
consequences, as I judge, may be imputed sometimes
to an acrid matter produced by the preceding disease,
and deposited in different parts; and sometimes to an
inflammatory diathesis produced, and determined to
particular parts of the body.

593. It is, I think, agreed among practitioners, that,
in the different cases of small-pox, the difference chief-
ly depends upon the appearance of distinct or conflu-
ent; and from the above description of these kinds, it
will appear, that they chiefly differ in the period of the
eruption, in the number of pustules produced, in the
form of the pustules, in the stale of the matter contain-
ed in them, in the continuance of the fever, and, lastly,
in the danger of the disease.

594. Upon inquiring into the causes of these differ-
ences, we might readily suspect, that they depended
upon a difference of the contagion producing the dis-
ease. This, however, is not probable; for there are in-
numerable instances of the contagion, arising from a
person labouring under the small-pox of the distinct
kind, producing the confluent; and on the contrary.
Since the practice of inoculation became frequent, we
have known the same variolous matter produce in one
person the distinct, and in another the eonfluent small-

PRACTICE OF PHYSIC. 371

pox. It is therefore highly probable, that the differ-
ence of the small-pox does not depend upon any differ-
ence of the contagion, but upon some difference in the
state of the person to whom it is applied, or in the state
of certain circumstances concurring with the applica-
tion of the contagion.

595. To find out wherein the difference in the state
of the persons to whom the contagion of the small-pox
is applied consists, I observe, that the difference be-
tween the distinct and confluent small-pox consists es-
pecially in the number of pustules produced, which, in
the distinct, are generally few^ in the confluent, always
many. If, therefore, we shall be able to discover what,
in the state of different persons, can give occasion to
more or fewer pustules, we shall probably be able to
account for all the other differences of the distinct and
confluent small-pox.

596. It is evident, that the contagion of the small-
pox is a ferment with respect to the human fluids, and
assimilates a great part of them to its own nature; and
it is probable, that the quantity thus assimilated is, in
proportion to the bulk of their several bodies, nearly
the same in different persons. This quantity passes
again out of the body, partly by insensible perspiration,
and partly by being deposited in pustules; but if the
quantities generated be nearly equal, the quantities pass-
ing out of the body by the two ways mentioned are
very unequal in different persons; and, therefore, if we
can explain the causes which determine more to pass
by the one way than by the other, we may thereby dis-
cover the causes which give occasion to more pustules
in one person than in another.

597. The causes which determine more of the vario-
lous matter to pass by perspiration, or to form pustules,
are probably certain circumstances of the skin, that do

376 PRACTICE OF PHYSIC.

termine more or less of the variolous matter to stick in
it, or to pass freely through it.

598. The circumstance of the skin, which seems to
determine the variolous matter to stick in it, is a certain
state of inflammation, depending much upon the heat of
it. Thus, we have many instances of parts of the body,
from being more heated, having a greater number of
pustules than other parts. In the present practice of ino-
culation, in which few pustules are produced, much
seems to be owing to the care that is taken to keep the
skin cool. Parts covered with plasters, especially with
those of a stimulant kind, have more pustules than
other parts. Further, certain circumstances, such as
adult age, and full living, determining to a phlogistic
diathesis, seem to produce a greater number of pus-
tules; while the contrary circumstances have contrary
effects.

599. It is therefore probable, that an inflammatory
state of the whole system, and more particularly of the
skin, gives occasion to a greater number of pustules;
and the causes of this may likewise produce most of
the other circumstances of the confluent smalJ-pox;
such as the period of eruption; the continuance of the
fever; the effusion of a more putrescent matter, and less
fit to be converted into pus; and, what arises from
thence, the form and other circumstances of the pus-
tules.

600. Having thus attempted to account for the chief
difference which occurs in the state of the smalJ-pox,
we shall now try the truth of our doctrine, by its appli-
cation to practice.

60 1. In considering the practice, we view it first, in
general, as suited to render the disease more gene-
rally benign and safe, and this by the practice of inocu-
lation.

PRACTICE OF PHYSIC. 373

602. It is not necessary here to describe the operation
of inoculating; and what we name the practice of ino-
culation, comprehends all the several measures which
precede or follow that operation, and are supposed to
produce its salutary effects.

These measures are chiefly the following:

1. The choosing for the subject of inoculation, per-
sons otherwise free from disease, and not liable, from
their age or other circumstances, to any incidental dis-
ease.

2. The choosing a person at the time of life most fa-
vourable to a mild disease.

3. The choosing for the practice a season the most
conducive to the mildness of the disease.

4. The preparing the person to be inoculated, by
abstinence from animal food, for some time before ino-
culation.

5. The preparing the person by courses of mercurial
and antimonial medicines.

6. The taking care, at the time of inoculation, to avoid
cold, intemperance, fear, or other circumstances which
might aggravate the future disease.

7. After these preparations and precautions, the choos-
ing a fit matter to be employed in inoculation, by taking
it from a person of a sound constitution, and free from
any disease or suspicion of it; by taking it from a per-
son who has had the small-pox of the most benign
kind; and, lastly, by taking the matter from such per-
sons, as soon as it has appeared in the pustules either
in the part inoculated, or on other parts of the body.

8. The introducing, by inoculation, but a small por-
tion of the contagious matter.

9. x\fter inoculation, the continuing the vegetable
diet, as well as the employment of mercurial and anti-

374 PRACTICE OF PHYSIC.

monial medicines, and, at the same time, frequently em-
ploying purgatives.

10. Both before and after inoculation, taking care to
avoid external heat, either from the sun, artificial fires,
warm chambers, much clothing, or being much in bed;
and, on the contrary, exposing the person to a free and
cool air.

11. Upon the appearance of the eruptive fever, the
rendering that moderate by the employment of purga-
tives, by the use of cooling and antiseptic acids, and
especially by exposing the person frequently to a cool,
and even a cold air, at the same time giving freely of
cold drink.

12. After the eruption, the continuing the applica-
tion of cold air, and the use of purgatives, during
the course of the disease, until the pustules are fully
ripened.

603. These are the measures proposed and practised
in the latest and most improved state of inoculation; and
the advantages obtained by the whole of the practice,
or at least by most of the measures above mentioned,
are now ascertained, by a long experience, to amount to
this. That in ninety-nine cases of the hundred, inocula-
tion gives a distinct small-pox only, and that also very
generally of the mildest form ; but it will still be useful,
for the proper conduct of inoculation, to consider the
importance and utility of the several measures above
mentioned, that we may thereby more exactly determine
upon what the advantages of inoculation more certainly
depend.

604. As the common infection may often seize per-
sons labouring under another disease, which may ren-
der the small-pox more violent, it is obvious that ino-
culation must have a great advantage, by avoiding such

PRACTICE OF PHYSIC. 375

concurrence. But as the avoiding such concurrence
may often, in the mean while, leave persons exposed to
the common infection, it merits inquiry, whether every
diseased state should restrain from the practice of ino-
culation, or what are the particular diseases that should
do so. This is not yet sufficiently ascertained by obser-
vation; and we have frequently remarked, that the small-
pox have often occurred with a diseased state of the
body, without being thereby rendered more violent. In
particular, we have observed, that a scrofulous habit, or
even the presence of scrofula, did not render the small-
pox more violent; and we have observed also, that seve-
ral diseases of the skin are equally innocent. I am of
opinion, that they are the diseases of the febrile kind, or
ailments ready to induce or aggravate a febrile state,
that especially give the concurrence which is most dan-
gerous with the small-pox. I dare not attempt any ge-
neral rules; but I am disposed to maintain, that, though
a person be in a diseased state, if that state be of un-
certain nature and effect, and, at the same time, the
small-pox be exceedingly rife, so as to render it ex-
tremely difficult to guard against the common infection,
it will always be safer to give the small-pox by inocula-
tion, than to leave the person to take them by the com-
mon infection.

605. Though inoculation has been practised with
safety upon persons of all ages; yet, from what has ac-
tually occurred in the cases of common infection, and
from several other considerations, there is reason to
conclude, that adults are more liable to a violent disease
than persons of younger years. At the same time, it is
observed, that children, in the time of their first denti-
tion, are liable, from this irritation, to have the small-
pox rendered more violent; and that infants, before the
time of dentition, upon receiving the contagion of the

376 PRACTICE OF PHYSIC.

small-pox, are liable to be affected with epileptic fits,
which frequently prove fatal. It is, therefore, upon the
whole, evident, that though circumstances may admit,
and even render inoculation at any age proper, yet, for
the most part, it will be still more advisable to choose
persons at an age, after the first dentition is over, and
before the time of puberty.

606. Though inoculation has been practised with
safety at every season of the year, yet, as it is certain
that the cold of winter may increase the inflammatory,
and the heats of summer increase the putrescent state
of the small-pox, it is highly probable, that inoculation
may have some advantage, from avoiding the extremes
either of heat or cold.

607. Although the original temperament and constitu-
tions of men are not to be readily changed, it is suffi-
ciently certain, that the conditions of the human body
may, by various causes, in many respects be occasion-
ally very much changed, and therefore as the use of
animal food may increase both the inflammatory and
putrescent state of the human body, so it must render
persons, on receiving the contagion of the small-pox,
less secure against a violent disease; and therefore ino-
culation may derive some advantage from abstinence
from animal food for some time before the inoculation
is performed: but I am of opinion, that a longer time
than that usually prescribed may be often necessary;
and I am persuaded, that the Scottish mothers who
avoid giving their children animal food till they are past
the small-pox, render this disease in them of a milder
kind.

608. 1 cannot deny that mercurial and antimonial me-
dicines may have some effect in determining to a more
free perspiration, and therefore may be of some use in
preparing a person for the small-pox; but there are

PRACTICE OF PHYSIC SI'

many observations which render me doubtful as to their
effect. The quantity of both these medicines, par-
ticularly of the antimony commonly employed, is too
inconsiderable to produce any effect. It is true that the
mercurials have often been employed more freely; but
even their salutary effects have not been evident, and
their mischievous effects have sometimes appeared. I
doubt, therefore, 'upon the whole, if inoculation derives
any advantage from these pretended preparatory courses
of medicines.

609. As it has been often observed, in the case of al-
most all contagions, that cold, intemperance, fear, and
some other circumstances, concurring with the applica-
tion of the contagion, have greatly aggravated the future
disease, so it must be the same in the case of the small-
pox; and it is undoubted, that inoculation must derive
a great, and perhaps its principal advantage, from avoid-
ing the concurrences above mentioned.

010. It has been commonly supposed, that inocula-
tion has derived some advantage from the choice of the
matter employed in it; but, from what has been observed
in 594, it must appear very doubtful if any choice be
necessary, or can be of any benefit in determining the
state of the disease.

611. It has been supposed by some, that inoculation
has an advantage, by introducing a small portion only
of the contagious matter: but this rests upon an uncer-
tain foundation. It is not known what quantity is intro-
duced by the common infection, and it may be a small
quantity only. Although it were larger than that thrown
in by inoculation, it is not ascertained that the circum-
stance of quantity would have any effect. A certain
quantity of ferment may be necessary to excite fermenta-
tion in a given mass: but that quantity given, the fer-
mentation and assimilation are extended to the whole

vol. i. 3 b

378 PRACTICE OF PHYSIC.

mass; and wo do not find that a greater quanf'ty than
is just necessary, either increases the activity of the fer-
mentation, or more certainly secures the assimilation ol
the whole. In the case of the small-pox, a considera-
ble difference in the quantity of contagious matter in-
troduced, has not discovered any effect in modifying the
disease.

612. Purging has the effect of diminishing the activity
of the sanguiferous system, and of obviating its inflam-
matory state. It is, therefore, probable, that the frequent
use of cooling purgatives is a practice attending inocu-
lation which may be of considerable advantage; and,
probably, it is also useful by diminishing ihe determina-
tion to the skin. It appears to me, that mercurials and
antimonials, as they are commonly managed, are useful
only as they make a part of the purging course.

613. It is probable, that the state of the small-pox de-
pends very much upon the state of the eruptive fever,
and particularly upon moderating the inflammatory state
of the skin; and, therefore, it is probable, that the mea-
sures taken for moderating the eruptive fever and in-
flammatory state of the skin, afford the greatest im-
provement which has been made in the practice of ino-
culation. The tendency of purging, and the use of
acids for this purpose is sufficiently obvious; and upon
the same ground we should suppose, that blood-letting
might be useful; but probably this has been omitted, for.
the same reason that might perhaps have led to the
omission of other remedies also; which is, that we have
found a more powerful and effectual one in the applica-
tion of cold air, and the use of cold drink. Whatever
doubts or difficulties our theory might present to us on
this subject, they may he entirely neglected, as the prac-
tice of Indostan had long ago, and the practice of this
country has lately, by a large and repeated experience,

PRACTICE OF PHYSIC. 379

ascertained the safety and efficacy of this remedy: and
as it may and can be more certainly employed with the
practice of inoculation, than it can be in cases of com-
mon infection, it must give a singular advantage to the
former.

614. After the eruption, when a few pimples only
have appeared on the face, the continuing the applica-
tion of cold air, and the employment of purgatives,
has indeed been the practice of many inoculators: but I
think these practices cannot be said to give any peculiar
advantages to inoculation; for when the state of the
eruption is determined, when the number of pustules
is very small, and the fever has entirely ceased, I hold
the safety of the disease to be absolutely ascertained,
and the further use of remedies entirely superfluous. In
such cases, I judge the use of purgatives to be not only
unnecessary, but that they may be often hurtful.

615. 1 have thus considered the several circumstances
and practices accompanying inoculation, and have en-
deavoured to ascertain the utility and importance of
each. Upon the whole, I hope I have sufficiently as-
certained the general utility and great advantage of this
practice, especially consisting in this, that if certain pre-
cautions, preparations, and remedies, are of importance,
all of them can be employed with more certainty in the
practice of inoculation, than in the case of common in-
fection.

It remains now that I should offer some remarks on
the conduct of the small-pox. as received by infection,
or even when, after inoculation, the symptoms shall
prove violent. The latter sometimes happens, although
every precaution and remedy have been employed. The
cause of this is not well known; but it appears to me to
be commonly owing to a disposition of the fluids to putres-
cency. But, however this may be, it will appear, that,

380 PRACTICE OF PHYSK

not only in the case of common infection, but even in
that of inoculation, there may be occasion for studying
the conduct of this disease, in all its possible varying
circumstances.

616. When, from the prevailing of small-pox as an
epidemic, and more especially when it is known that a
person, not formerly affected with the disease, has been
exposed to the infection, if such person should be seized
with the symptoms of fever, there can be little doubt of
its being an attack of the small-pox; and, therefore, he is
to be treated in every respect as if the disease had been
received by inoculation. He is to be freely exposed to
a cool air, to be purged, and to have cooling acids given
liberally.

617. If these measures moderate the fever, nothing
more is necessary: but if the nature of the fever attack-
ing a person be uncertain; or if, with suspicions of the
small-pox, the symptoms of the fever be violent: or even
if, knowing the disease to be the small-pox, the measures
mentioned (596.) shall not moderate the fever suffici-
ciently; it will be proper to let some blood: and this
will be more especially proper, if the person be an adult,
of a plethoric habit, and accustomed to full living.

618. In the same circumstances, we judge it will be
always proper to give a vomit, as useful in the com-
mencement of all fevers, and more especially in this,
where a determination to the stomach appears from
pain aud spontaneous vomiting.

619. It frequently happens, especially in infants, that
during the eruptive fever of the small-pox, convulsions
occur. Of these, if only one or two fits appear on the
evening preceding the eruption, they give a favourable
prognostic of a mild disease, and require no remedy;
but if they occur more early, and be violent and fre-
quently repeated, they are very dangerous, and require

PRACTICE OF PHYSIC. 381

a speedy remedy. For this purpose, bleeding is hardly
ever of service; blistering always comes too late; and
the only remedy I have found effectual, is an opiate
given in a large dose.

620. These are the remedies necessary during the
eruptive fever; and if, upon the eruption, the pimples
upon the face be very few and distinct, the disease is no
further of any danger, requires no remedies, and the
purgatives, which, as has been said before, are by some
practitioners continued, prove often hurtful.

But when, upon the eruption, the pimples on the face
are very numerous; when they are not distinct; and es-
pecially when, upon the fifth day, the fever does not suf-
fer a considerable remission, the disease will still re-
quire a great deal of attention.

6,21. If, after the eruption, the fever shall continue,
the avoiding heat, and continuing to expose the body to
a cool air, will still be proper. If the fever be con-
siderable, with a full and hard pulse, in an adult person,
a bleeding will be necessary; and, more certainly, a
cooling purgative. It is, however, seldom that a repe-
tition of the bleeding will be proper, as a loss of strength
does usually come on very soon; but the repetition of a
purgative, or the frequent use of laxative glysters, is
commonly useful.

622. When loss of strength, with other marks of a
putrescent tendency of the fluids, appears, it will be ne-
cessary to exhibit the Peruvian bark in substance, and
in large quantity. In the same case, the free use of
acids, and of nitre, is useful; and it is commonly proper
also to give wine very freely.

623. From the fifth day of the disease, onward through
the whole course of it, it is proper to give an opiate
once or twice a-day; taking care, at the same time, to
obviate costiveness, by purgatives or laxative glysters.

382 PRACTICE OF PHYSIC.

624. In a violent disease, from the eighth to the ele-
venth day, it is proper to lay on blisters successively on
diffident parts of the body; and that without regard to
the parts being covered with pustules.

625. If, in this disease, the tumour of the fauces be
considerable; the deglutition difficult; the saliva and mu-
cus viscid, and with difficulty thrown out; it will be
proper to apply blisters to the external fauces, and to
employ diligently detergent gargles.

626. During the whole course of the disease, when
any considerable fever is present, the frequent exhibi-
tion of antimonial medicines, in nauseating doses, has
been found useful; and these, for the most part, suffi-
ciently answer the purpose of purgatives.

627. The remedies mentioned from 621. to 625. are
those frequently necessary, from the fifth day till the
suppuration is finished. But as, after that period, the
fever is sometimes continued and increased; or, as some-
times, when after there has been little or no fever be-
fore, a fever now arises, and continues with considera-
ble danger; this is what is called the Secondary Fever,
and requires particular treatment.

628. When the secondary fever follows the distinct
small-pox, and the pulse is full and hard, the case is to
be treated as an inflammatory affection, by bleeding and
purging, but if the secondary fever follow the confluent
small-pox, and be a continuance or exacerbation of the
fever which had subsisted before, it is to be considered
as of the putrid kind; and in that case, bleeding is im-
proper. Some purging may be necessary; but the re-
medies to be chiefly depended on, are the Peruvian
bark and acids.

When the secondary fever first appears, whether it is
after a distinct or confluent small-pox, it will be useful

PRACTICE OF PHYSIC. 383

to exhibit an antimonial emetic in nauseating doses, but
in such a manner as to produce some vomiting.

629; For avoiding the pits which frequently follow
the small-pox, many different measures have been pro-
posed; but none of them appear to be sufficiently certain.

CHAPTER II.
OF THE CHICKEN-POX.*

630. THIS disease seems to depend upon a specific
contagion, and to affect persons but once in their lives,
It is hardly ever attended with any danger; but as it
seems frequently to have given occasion to the supposi-
tion of a person's having the small-pox twice, it is proper
to study this disease, and to distinguish it from the ge-
nuine small-pox.

631. This may be generally done by attending to the
following circumstances. ,

The eruption of the chicken-pox comes on with very
little fever preceding it, or with fever of no determined
duration.

* Chicken-pox, being a febrile disease of excessive action, requires, at
all times, as far as medical aid may become necessary in it, the antiphlogistic
plan of treatment. Of the extent to which this plan should be carried, the
practitioner will easily judge from the character of the attack.

Sometimes, from improper exposure, or other causes, the eruption, before
it is completed, suddenly disappears. In such cases, considerable nausea,
or vomiting, and prostration of strength almost immediately ensue

Under such circumstances, an emetic, by changing the action of the sto-
mach, and determining again to the surface, is highly useful.

This, followed by the use of warm sage, or balm tea, or some other vege-
table infusion, gently stimulating, restores the eruption and relieves the
complaint.

All eruptive diseases, we have said, originate in the stomach. This truth
very clearly appears, from the serious manner in which that organ suffers,
when, from any cause, the eruption recedes from the surface of the bodv.

384 PRACTICE OF PHYSIC.

The pimples of the chicken-pox, more quickly than
those of the small-pox, are formed into little vesicles or
pustules.

The matter in these pustules remains fluid, and never
acquires the colour or consistence of the pus which ap-
pears in the pustules of the small-pox.

The pustules of the chicken-pox are always, in three
or four days from their first appearance, formed into
crusts.

See Dr. Heberden in Med. Transact. Vol. I. art. xvii.

CIIAFTEll III.
OF THE MEASLES.

632. XHIS disease also depends upon a specific conta-
gion, and affects persons but once in their lives.*

* However visionary it might appear in us to doubt; or heterodox to deny,
the contagious nature of measles, we acknowledge ourselves unable, defini-
tively, to prove it.

Measles cannot be propagated by inoculation; the oidy conclusive test of
contagion with which we are acquainted. Every other may prove delusive.

This complaint, when it does prevail, assumes, we believe, always, the cha-
racter of an epidemic ,• which is only another name for an atmospheric disease.
There exists not a doubt, therefore, that it often, at least, makes its appear-
ance in places, into which it has not been introduced by means of contagion.
We have repeatedly been witness to such an occurrence.

If, from a place where measles prevails, one or more cases be removed to
a distant part, where it did not before exist, it does not spread from the sick
as from a centre of contagion. It usually, if not uniformly, disappears, with
the death or recovery of the persons affected. Nor is it until it arrives at
this place, in the form of an epidemic, that it actually spreads among the in-
habitants. Of this we speak confidently, for we have witnessed the event.
If it be contagious, therefore, the laws of its communication are materially
different from those of small-pox— a disease, which, in all places, and under
all circumstances, spreads among those who have not been affected by it ;
provided they come within the sphere of its action.

The strongest marks of a specifically contagious disease which measles

PRACTICE OF PHYSIC. 385

ti33. It occurs most frequently in children; but no
age is exempted from it, if the persons have not been
subjected to it before.

6.34. It commonly appears as an epidemic, first in
the month of January, and ceases soon after the sum-
mer solstice; but various accidents, introducing the con-
tagion, may produce the disease at other times of the

year.

635. The disease always begins with a cold stage,
which is soon followed by a hot, with the ordinary
symptoms of thirst, heat, anorexia, anxiety, sickness,
and vomiting; and these are more or less considerable
in different cases. Sometimes, from the beginning, the
fever is sharp and violent; often, for the first two days,
it is obscure and inconsiderable, but always becomes
violent before the eruption, which usually happens
upon the fourth day*

636. This eruptive fever, from its commencement, is
always attended with hoarseness, with a frequent hoarse
dry cough, and frequently with some difficulty of breath-
ing. At the same time, the eye-lids are somewhat
swelled, the eyes are a little inflamed, and pour out
tears; and, together with these symptoms, there is a
coryza, and frequent sneezing. For the most part, a
constant drowsiness attends the beginning of this dis-
ease.

637. The eruption, as we have said, commonly ap-
pears upon the fourth day, first on the face, and succes-

possesses, are, its peculiar appearance, and that it affects persons but once
in the course of their lives Remove these characteristics, and the evi-
dences of its contagion are scarcely stronger than those that are exhibited
by intermitting fever.

» We have known the fever of measles to have continued more than a week,
before the appearance of the eruption. A case of this kind fell, very ir
cently, under our notice.

vol. I. 3 r

386 PRACTICE OF PHYSIC.

sively on the lower parts of the body. It discovers
itself first in small red points; but, soon after, a num-
ber of these appear in clusters, which do uot arise into
visible pimples, but, by the touch are found to be a little
prominent. This is the case on the face; but, on other
parts of the body, the prominence, or roughness, is
hardly to be perceived. On the face the eruption re-
tains its redness, or has that increased for two days:
but, on the third, the vivid redness is changed to a
brownish red; and, in a day or two more, the eruption
entirely disappears, while a mealy desquamation takes
place. During the whole time of the eruption, the face
is somewhat turgid, but seldom considerably swelled.

638. Sometimes, after the eruption has appeared, the
fever ceases entirely: but this is seldom the case; and
more commonly the fever continues, or is increased
after the eruption, and does not cease till after the des-
quamation. Even then the fever does not always cease,
but continues with various duration and effect.

639. Though the fever happen to cease upon the
eruption's taking place, it is common for the cough to
continue till after the desquamation, and sometimes
much longer.

In all cases, while the fever continues, the cough also
continues, generally with an increase of the difficulty of
breathing; and both these symptoms sometimes arise to
a degree that denotes a pneumonic affection. This
may arise at any period of the disease; but very often it
does not come on till after the desquamation of the
eruption.

After the same period, also, a diarrhoea frequently
comes on, and continues for some time.

640. It is common for the measles, even when they
have not been of a violent kind, to be succeeded by

PRACTICE OF PHYSIC. 387

inflammatory affections, particularly ophthalmia and
phthisis.*

641. If the blood be drawn from a vein during the
measles, with the circumstances necessary to favour the
separation of the gluten, this always appears separated,
and lying on the surface of the crassamentum, as in in-
flammatory diseases.

642. For the most part, the measles, even when vio-
lent, are without any putrid tendency, but in some cases,
such a tendency appears, both in the course of the dis-
ease, and especially after the ordinary course of it is
finished. See Dr. Watson, in London Med. Observa-
tions, Vol. IV. art. xi.

643. From what is delivered, from 636. to 641, it
will appear, that the measles are distinguished by a ca-
tarrhal affection, and by an inflammatory diathesis to a
considerable degree, and therefore the danger attending
them arises chiefly from the coming on of a pneumonic
inflammation.

644. From this consideration it will be obvious, that
the remedies especially necessary, are those which may
obviate and diminish the inflammatory diathesis; and
therefore, in a particular manner, blood-letting. This
remedy may be employed at any time in the course of
the disease, or after its ordinary course is finished. It
is to be employed more or less according to the urgency
of the symptoms of fever, cough, and dyspnoea; and
generally may be employed very freely. But as the
symptoms of pneumonic inflammation seldom come on
during the eruptive fever; and, as this fever is some-
times violent immediately before the eruption, though a
sufficiently mild disease be to follow; so bleeding is sel-

* These unfavourable terminations of measles very rarely occur, except
as the result of neglect or unskilful treatment. Practise venesection to a
sufficient extent, and avoid cold and improper exposure, and you effectuallv
prevent them,

3S8 PRACTICE OF PHYSIC.

dom very necessary during the eruptive fever, and m

often be reserved for the periods of greater danger

which perhaps are to ensue.*
645. In all cases of measles, where there are no marks

of putrescency, and where there is no reason, from the
known nature of the epidemic, to apprehend putres-
cency, bleeding is the remedy to be depended upon; but
assistance may also be obtained from cooling purga-
tives; and particularly from blistering on the sides, or
between the shoulders.f

646. The dry cough may be alleviated by the large
use of demulcent pectorals, mucilaginous, oily, or sweet.
It may, however, be observed, with respect to these de-
mulcents, that they are not so powerful in involving and
correcting the acrimony of the mass of blood as has
been imagined; and that their chief operation is by be-
smearing the fauces, and thereby defending them from
the irritation of acrids, either arising from the lungs, or
distilling from the head.J

647. For moderating and quieting the cough in this
disease, opiates certainly prove the most effectual means,
whenever they can be safely employed. In the measles,
in which an inflammatory state prevails in a considerable
degree, opiates may be supposed to be inadmissible;
and, in those cases in which a high degree of pyrexia

• We are inclined to believe, that the judicious employment of the lancet.,
as well as of emetics, facilitates very much the appearance of the eruption.
Confident we are, that venesection, during the eruptive fever, often affords
immediate relief, without being productive of subsequent injury. It is, there-
fore, a valuable remedy.

| When symptoms of pneumonic inflammation exist, blistering on some
part of the thorax, the part to be directed by the seat of the pain, is as es-
sential in measles as it is in peripneumony.

$ Flax-seed tea, bran tea, barley water, and gum arabic dissolved in wa-
ter, make excellent drinks in measles ; but, with the oily preparations we
are not pleased, because we consider them too stimulating. They excite too
much action in the stomach, and, hence, in other parts, by sympathy. The
Mood, we believe, to be as free from acrimony in measles, as it is in health

PRACTICE OF PHYSIC. 389

and dyspnoea show either the presence, or at least the
danger, of pneumonic inflammation, I think that opiates
might be very hurtful. In cases, however, in which the
dyspnoea is not considerable, and where bleeding, to
obviate or abate the inflammatory state, has been duly
employed, and where the cough and watchfulness are
the urgent symptoms, I think that opiates may be safely
exhibited, and with great advantage. I think, further,
that in all the exanthemata, there is an acrimony dif-
fused over the system, which gives a considerable irrita-
tion; and, for obviating the etfects of this, opiates are
useful, and always proper, when no particular contra-
indication prevails.*

648. When the desquamation of the measles is finish-
ed, though there should then be no disorder remaining,
physicians have thought it necessary to purge the pa-
tient several times, with a view to draw off' the dregs
of this disease, that is, a portion of the morbific mat-
ter which is supposed to remain long in the body. I can-
not reject this supposition; but, at the same time, cannot
believe, that the remains of the morbific matter, dif-
fused over the whole mass of blood, can be entirely
drawn off by purging; and, it appears to me, that, to
avoid the consequences of the measles, it is not the
drawing off the morbific matter which we need to study,

* When, by means of blood-letting, and other remedies, the febrile symp-
toms are so far subdued, that the complaint is little else than a disease of
local irritation, opiates should be administered precisely as in other diseases
of a similar character. To relieve the cough, which always accompanies
measles, and the diarrhaa, which often makes its appearance towards the
close of the complaint, opiates, in some form, constitute the only effectual
remedy. The following formula, we have found pleasant and useful : viz.
R Mucilag. Gum, Arab. )

Aq. Cinnamom. seu Lavend. simp.$ ^ * n '

Aq. Font. |iy.

Tinct. Thebaic. 3i.

Sacch. alb. q. s. m. ft. Julep.
Of this, a full table-spoonful may be taken at a dose, by an adult, and re-
peated as often as circumstances require it.

390 PRACTICE OF PHYSIC.

so much as the obviating and removing the inflamma-
tory state of the system which had been induced by the
disease. With this last view, indeed, purging may still
be a proper remedy ; but bleeding, in proportion to the
symptoms of inflammatory disposition, is yet more so.*

649. From our late experience of the benefit of cold
air in the eruptive fever of the small-pox, some physi-
cians have been of opinion that the practice might be
transferred to the measles: but we have not yet had
trials sufficient to ascertain this.

There is no doubt that external heat may be very
hurtful in the measles, as in most other inflammatory
diseases; and therefore the body ought to be kept in a
moderate temperature during the whole course of the
measles; but how far, at any period of the disease, cold
air may be applied with safety, we are yet uncertain.
Analogy, though so often the resource of physicians, is,
in general, fallacious; and further, though the analogy
with the small-pox might lead to the application of cold
air during the eruptive fever of the measles, the analogy
with catarrh seems to be against the practice. After
the eruption had appeared upon the skin, we have had
many instances of cold air making it disappear, and
thereby producing much disorder in the system; and
have also had frequent examples of such disorder being
removed by restoring the heat of the body, and thereby
again bringing forth the eruption.f

* If, in this article, the mind of Dr. Cullen be correctly represented, it
retained a strong bias towards the errors of the humoral pathology

In case inflammation, on the decline of measles, threaten to fix itself
in an ophthalmic, a catarrhal, or a pneumonic form, the liberal use of the lan-
cet, of blisters, and other antiphlogistic remedies, becomes essential. Under
these circumstances, no truce should be given to the disease ; but it ought
to be resolutely, and' perse veringly assailed, until it be completely eradicat-
ed. This measure we hold to be essential ; for, there is no complaint, which,
if neglected towards its close, leaves behind it more troublesome affections
than measles.

f The temperature of the chamber, in the treatment of measles, should

PRACTICE OF PHYSIC. 391

CHAPTER IV.

OF THE SCARLET FEVER.*

650. IT may be doubted if the scarlet fever be a dis-
ease specifically different from the Cynanche Maligna
above described. The latter is almost always attended
with a scarlet eruption; and, in all the instances I have
seen of what may be called the scarlet fever, the dis-
ease, in almost every person affected, has been attend-
ed with an ulcerous sore throat.

be precisely the same as in that of peripneumony— moderate— not in either
extreme. Of the two, a temperature a little too high, is less apt to prove
injurious, than one too low. Here, as in the treatment of most other febrile
affections, the punctum jucundum of temperature should be carefully preserv-
ed. Whatever degree of heat or cold produces, on the system, an unpleasant
impression, is an irritant, will increase fever, and ought, therefore, to be
avoided.

* Notwithstanding all Dr. Cullen's reasoning in this chapter, we are
strongly inclined to believe, that Scarlatina Anginosa, and Cynanche Ma-
ligna, are but different forms or degrees of the same disease. They stand
related to each other, precisely as the distinct and the confluent small-pox -
wh.ch were also, at a former, and not a very remote period, regarded as dis-
eases specifically different.

Indeed, we think the identity of Scarlatina Anginosa, and Cynanche Ma-
l.gna, very fairly to be inferred, even from the statement of our author re
spectmg them : for, he admits, that, when epidemic, these forms of disease
always accompany each other; but in inverse ratios: and, it is well known
that two ep.demics never prevail at the same time. They must, therefore'

11 J?? , Wed ° Ubt ' h ° WeVer ' their -« ^ing propagated by co a
ff on. We feel persuaded they never are , but, that they are exclusively at-
rnosphenc d.sease, They both have their primary affection in the stl

The poison of scarlatina anginosa, whatever may be its nature, operates

SET Vr™ ^ * reat,y dissimiI - ^ the operation Arsenic

thro, Vn T P rod "«s sickness at stomach, an inflammation of the

does h 1 r C % an T UPti ° n °" thC Skin ' aBd Sn anaS — filing. So

does th matter of scarlatma anginosa. But arsenic, in producing its effects

cts on the stomach alone. So, we are persuaded, does the poifon of scar

392 PRACTICE OF PHYSIC:

651 . This view of the matter may create some doubt;
but I am still of opinion, that there is a scarlet fever
which is a disease specifically different from the Cy-
nanche Maligna.

Dr. Sydenham has described a scarlet fever, which
he had seen prevailing as an epidemic, with all the cir-
cumstances of the fever and eruption, without its being
accompanied with any affection of the throat; at least
he does not take notice of any such affection, which
such an accurate observer could not fail to have done,
if any such symptom, as we have commonly seen mak-
ing a principal part of the disease, had attended those
cases which he had observed. Several other writers
have described the scarlet fever in the same manner,
and 1 know physicians who have seen the disease in
that form; so that there can be no doubt of there being
a scarlet fever not necessarily connected with an ulcer-
ous sore throat, and therefore a disease different from
the Cynanche Maligna.

652. But, further, although in all the instances of
scarlet fever which I have seen, (and in the course of
forty years I have seen it six or seven times prevailing
as an epidemic in Scotland) the disease, in almost all
the persons affected, was attended with an ulcerous sore
throat, or was what Sauvages names the Scarlatina
Anginosa; and although, in some instances the ulcers
of the throat were of a putrid and gangrenous kind, and
at the same time the disease in all its symptoms resem-
bled very exactly the Cynanche Maligna; yet I am still
persuaded, that not only the Scarlatina of Sydenham,
but that even the Scarlatina Anginosa of Sauvages, is
a different disease from the Cynanche Maligna; and I
have formed this opinion from the following considera-
tions:

653. 1st. There is a scarlet fever entirely free from

PRACTICE OF PHYSIC. 39S

any affection of the throat which sometimes prevails as
an epidemic; and therefore there is a specific contagion
producing a scarlet eruption without any determination
to the throat.

2dly, The Scarlatina, which, from its matter being
generally determined to the throat, may be properly
termed Anginosa, has, in many cases of the same epi-
demic, been without any affection of the throat; and
therefore the contagion may be supposed to be more
especially determined to produce the eruption only.

3dly, Though in all the epidemics that I could allege
to be those of tiie Scarlatina Anginosa, there have been
some cases, which, in the nature of the ulcers, and in
other circumstances, exactly resembled the cases of the
Cynanche Maligna; yet I have as constantly remarked,
that these cases have not been above one or two in a
hundred, while the rest have all of them been with ul-
cers of a benign kind, and with circumstances hereaf-
ter to be described, somewhat different from those of
the Cynanche Maligna.

4thly, On the other hand, as I have two or three times
seen the Cynanche Maligna epidemically prevailing; so,
among the persons affected, I have seen instances of
cases as mild as those of the Scarlatina Anginosa usu-
ally are: but here the proportion was reversed; these
mild cases were not one fifth of the whole, while the
rest were of the putrid and malignant kind.

Lastly, It applies to the same purpose to observe,
that, of the Cynanche Maligna, most of the instances
terminate fatally; while, on the other hand, that is the
event of very few of the cases of the Scarlatina An-
ginosa.

654. From these considerations, though it may ap-
pear that there is some affinity between the Cynanche
Maligna and Scarlatina Anginosa, it will still remain

vol, i. 3d

394 PRACTICE OF PHYSIC .

probable that the two diseases are specifically different,
I have been at some pains to establish this opinion: for,
from all my experience, I find, that those two diseases
require a different treatment; and I therefore now pro-
ceed to mention more particularly the circumstances oi
the Scarlatina Anginosa.

655. This disease- commonly appears about the be-
ginning of winter, and continues throughout that season.
It comes on with some cold shivering, and other symp-
toms of the fever which usually introduces the other
exanthemata. But here there is no cough, nor the
other catarrhal symptoms which attend the measles;
nor is there that anxiety and vomiting which commonly
introduce the confluent small-pox, and which more
certainly introduce the Cynanche Maligna.

Early in the disease some uneasiness is felt in the
throat; and frequently the deglutition is difficult, gene-
rally more so than in the Cynanche Maligna. Upon
looking into the fauces, a redness and swelling appear,
in colour and bulk approaching to the state of these
symptoms in the Cynanche Tonsillaris; but in the Scar-
latina there is always more or less of sloughs, which
seldom appear in the Cynanche Tonsillaris; and the
sloughs are commonly whiter than those in the Cynan-
che Maligna.

While these appearances are discovered in the fau-
ces, upon the third or fourth day, a scarlet eruption ap-
pears on the skin, in the same form as described in
311. This eruption is commonly more considerable
and universal than in the Cynanche; but it seldom pro-
duces a remission of the fever. The eruption for the
most part remains till the third or fourth day after its
first appearance; but then goes off, ending in a meally
desquamation. At this time the fever usually subsides

PRACTICE OF PHYSIC. 395

and generally, at the same time, some degree of sweat
comes on.

The sloughs on the fauces,, which appeared early in
the disease, continue for some days; but then falling off,
discover the swelling abated, and an ulcer formed on
one or both tonsils showing a laudable pus; and soon
after the fever has subsided, these ulcers heal up en-
tirely. For the most part this disease has much less
of coryza attending it than the Cynanche Maligna; and,
when there is a coryza attending the Scarlatina, the
matter discharged is less acrid, and has not the fetid
smell which it has in the other disease.

In the Scarlatina, when the eruption has entirely
disappeared, it frequently happens, that in a few days
after, the whole body is affected with an anasarcous
swelling; which, however, in a few days more, gradu-
ally subsides.

We have thus described the most common circum-
stances of the Scarlatina Anginosa; and have only to
add, that during the time of its being epidemic, and es-
pecially upon its first setting in, there are always a few
cases in which the circumstances of the disease ap-
proach very nearly to those of the Cynanche Maligna:
and it is only in these instances that the disease is at-
tended with any danger.

656. With respect to the cure of this disease, when
the symptoms of it are nearly the same with those of
the Cynanche Maligna, it requires exactly the same
treatment as directed in 317.

657. When the scarlet fever appears without any af-
fection of the throat, the treatment of it is very simple,
and is delivered by Dr. Sydenham. An antiphlogistic
regimen is commonly all that is requisite; avoiding, on
one hand, the application of cold air; and, on the other,
any increase of external heat.

396 PRACTICE or P1IYSK

658. In the ordinary state of the Scarlatina Angihosa,
the same treatment is. in most cases, sufficient; but as
here the fever is commonly more considerable, and
there is likewise an affection of the throat, some reme-
dies may be often necessary.

659. When there is a pretty high degree of fever,
with a full pulse, and a considerable swelling of the
tonsils, bleeding is very proper, especially in adults; and
it has been frequently practised with advantage: but as,
even in the Cynanche Tonsillaris, much bleeding is
seldom necessary (305.): so, in the Scarlatina, when
the state of the fever and the appearances of the fauces
render the nature of the disease ambiguous, bleeding
may be omitted ; and, if not altogether avoided, it should
at least not be large; and ought not to be repeated.*

660. Vomiting, and especially nauseating doses of
emetics, notwithstanding the inflamed state of the
fauces, have been found very useful in this disease.
An open belly is proper in every form of this disease;
and when the nauseating doses of emetics operate a
little downwards they are more serviceable.!

661. Fn every form of the Scarlatina Anginosa,
through the whole course of it, detergent gargles should
be employed, and more or less as the quantity of

* In most cases of Scarlatina Anginosa, that are, in any measure, severe,
blood-letting constitutes an important remedy: in many, it may be several
times repeated with advantage In the United States, where the type of
this disease is, perhaps, more inflammatory than in Great Britain, it is very
seldom other than a safe remedy.

When the affection of the throat is troublesome, blistering externally
should never be omitted ; the febrile action being previously reduced by
evacuating remedies.

f Emetics, particularly at the commencement of the disease, are highly
useful. They relieve the stomach, determine to the skin, and break, in
some measure, or, at least, weaken, the chain of diseased action, wherein
the malady consists. In nauseating doses, they serve, in part, as a substitute
for blood-lettiner.

PRACTICE OF PHYSIC. 397

sloughs and the viscid mucus in the fauces may seem
to require.*

662. liven in the milder states of the Scarlatina An-
ginosa, it has been common with practitioners to exhi-
bit the Peruvian bark through the whole course of the
disease; but we are assured, by much experience, that
in such cases it may be safely omitted, though in cases
any ways ambiguous it may not be prudent to neglect
this remedy.

663. The anasarcous swelling, which frequently fol-
lows the Scarlatina Anginosa, seldom requires any re-
medy; and, at least, the purgatives so much inculcated,
and so commonly exhibited, soon take off the anasarca.

chapter v.

OF THE PLAGUE.f

Sect. I. — Of the Phenomena of the Plague.

€64 THE Plague is a disease which always arises
from contagion; which affects many persons about the

* Aqueous gargles are rendered sufficiently detergent, by proper admix-
tures of vinegar, tincture of myrrh, or muriatic acid. The judicious em-
ployment of such remedies, accelerates the cure of the topical affection.
When the disease has terminated, and convalescence commenced, a mild,
but nutritious diet, constitutes the most efficacious tonic that can be ad-
ministered.

f We have already observed, that we do not believe plague to be a con-
tagious disease. Knowing that this opinion is, by most people, perhaps, re-
garded as heterodox, we feel ourselves bound to give our reasons for enter-
taining it. They are as follow :

I. Plague has never been certainly propagated by inoculation. This is
true, notwithstanding all that has been said to the contrary. The instances
in which attempts at inoculation have been made, are reported in a manner
so loose and unsatisfactory, that no inference, absolutely conclusive, can, in
any way, be drawn from them. On the whole, however, they afford, to a

398 PRACTICE OF PHYSIC.

same time; proves fatal to great numbers; generally pro-
duces fever; and, in most persons, is attended with bu-
boes or carbuncles.

mind accustomed to analysis, no evidence that the attempts ever succeeded.
It is true, that persons who had been inoculated, afterwards sickened and
died of the plague, lint, from the vague and uncircumstantial manner in
which their cases are described, it is impossible to determine, whether the
disease was contracted from inoculation, or from some other source. The
latter supposition appears to us by far the most probable.

II. There exists in plague no morbid glands, by which a specific poison
might be secreted ; and, therefore, no source to supply the contagion. Bu-
boes cannot be regarded as such, because they do not appear in every case
of the disease; nor, when they do make their appearance, are they always
converted into open sores : and carbuncles, which are, in fact, nothing but
spots of gangrenous inflammation, occur, comparatively speaking, in but few
cases of the disease.

1IT. riague is a disease of circumscribed prevalence, whether it be consi-
dered in relation to place or time. It spreads only in given situations, under
particular circumstances, and at certain seasons of the year. In Constanti-
nople, the cold of the winter, and in Egypt, the heat and dryness of the sum-
mer, completely check it.

But this is not the character of a contagious disease. Contagion, as for-
merly stated, is a secreted poison : it may be, therefore, and actually is,
formed, indifferently, at every season, and in every situation — in the winter
and summer, as well as in the spring or autumn ; in the country, as well as
in cities ; in elevated regions, as readily as in low ones ; and, in every degree
of latitude, from the line to the poles. Of the truth of this, small-pox, cow-
pox, and lues venera, afford conclusive evidence.

IV. If a case of plague be removed from the vitiated atmosphere, where
the disease prevails, to a situation where the air is entirely free from septic
effluvia, it is never communicated to physicians or visitants, nurses, or attend-
ants. This fact appears to be as conclusively established as any one em-
braced in the history of the disease. It is confirmed even by the writings of
Dr. Russell himself, the great apostle of pestilential contagion. Plague,
then, will not spread without the limits of a contaminated atmosphere; and
is, hence, most palpably an atmospheric disease.

How different is the case in relation to small-pox, to the spreading of which
every condition of the air is equally favourable ! The reason is obvious. This
disease depends for its propagation on a specific poison, generated by mor-
bid action, which that poison itself excites. The action of this virus the
condition of the air can neither assist nor prevent.

But plague depends, for its existence, on a contaminated atmosphere ; and
dies for want of nourishment if the air be pure.

Nothing appears to us to be more truly absurd, than to contend for the con-
tagious nature of a disease of this description. Real febrile contagion is a
poison as absolute and independent as opium or henbane, arsenic or corro-

PRACTICE OF PHYSIC. 399

665. These are the circumstances, which, taken to-
gether, give the character of the disease; but it is ac-
companied with many symptoms almost peculiar to it-
self, that, in different persons, are greatly diversified in
number and degree, and should be particularly studied.
I would wish to lay a foundation for this; but think it
unfit for a person who has never seen the disease to
attempt its particular history. For this, therefore, I
must refer to the authors who have written on the sub-
ject; but allowing those only to be consulted, who have
themselves seen and treated the disease in all its differ-
ent forms.

666. From the accounts of such authors, it appears
to me, that the circumstances which particularly distin-
guish this disease, and especially the more violent and
dangerous states of it, are,

1st, The great loss of strength in the animal func-
tions, which often appears early in the disease.

2dly, The stupor, giddiness, and consequent stagger-
ing, which resembles drunkenness, or the headach, and
various delirium: which are all of them symptoms de-
noting a great disorder in the functions of the brain.

3e%, The anxiety, palpitation, syncope, and especial-
ly the weakness and irregularity of the pulse, which
denote a considerable disturbance in the action of the
heart.

Mhhj, The nausea and vomiting, particularly the vo-
miting of bile, which shows an accumulation of vitiated
bile in the gall-bladder and biliary ducts, and from
thence derived into the intestines and stomach; all of

sive sublimate ; and operates as exclusively by its own powers. As well,
therefore, might we represent either of the latter to be capable of acting
only under the influence of a given condition of the atmosphere, as the for-
mer. The very idea of a poison pre-supposes an inherent and self-depend-
entpower to act deleteriously : and this definition applies to the poison of
contagion, as well as to every other.

400 PRACTICE OF PHYSIC.

which symptoms I suppose to denote a considerable
spasm, and loss of lone, in the extreme vessels on the
surface of the body.

5thly, The buboes or carbuncles, which denote an
acrimony prevailing in the fluids. And,

Lastly, The petechias, ha3morrhagies, and colliqua-
tive diarrhoea, which denote a putrescent tendency pre-
vailing to a great degree in the mass of blood.*

667. From the consideration of all these symptoms,
it appears, that the plague is especially distinguished by
a specific contagion, often suddenly producing the most
considerable symptoms of debility in the nervous sys-
tem or moving powers, as well as of a general putres-
cency in the fluids; and it is from the consideration of
these circumstances as the proximate cause, that I think
both the prevention and cure of the plague must be di-
rected.

668. If this disease should revisit the northern parts
of Europe, it is probable, that, at the time, there will
be no physician then alive, who, at the first appearauce

* We think our author's exposition of the pathology, or ratio symptoma-
tum, of plague, which he attempts in this article, highly exceptionable.

" The stupor, giddiness, and consequent staggering," with the " head-
ach and various delirium," which he considers as " denoting a great disorder
in the functions of the brain ;" " the anxiety, palpitation, syncope, and the
weakness and irregularity of the pulse, which denote," as bethinks, "adis-
turbance in the action of the heart ;'' " the buboes and carbuncles," which
he derives from a prevailing acrimony in the blood ; and " the petechia,
hemorrhagies, and colliquative diarrhoea, which denote," as he alleges, "a
putrescent tendency prevailing to a great degree in the mass of blood"— all
these symptoms, instead of being explicable on the professor's principles,
may be much more fairly and rationally attributed to an inflamed, or other-
wise highly disordered, condition of the stomach. We well know, that
symptoms of the foregoing description, may originate in such a condition of
the stomach, and, we feel persuaded, that, in the present instance, such is
their source. Indeed, we are convinced, that the more accurately the plague
and the yellow fever shall be examined, the more they will be found to re-
semble, in their pathology, a species of gastrins.

We might here repeat what we have already observed, that pestis vera be-
longs more properly to the order phlegmasia:, than to that of exanthemata

PRACTICE OF PHYSIC. 401

of the disease, can be guided by his former experience,
but must be instructed by his study of the writers on
this subject, and by analogy. It is, therefore, I hope,
allowable for me, upon the same grounds, to ofleiyhere
my opinion with respect to both the prevention and
cure of this disease.

This paragraph was written before I had any notice
of the plague of Moscow, anno 1771; but I think it
will still apply to the case of Great Britain, and of many
other northern states.

Sect. II. — Of the Prevention of the Plague*

669. With respect to the prevention: as we are firmly
persuaded that the disease never arises in the northern
parts of Europe, but in consequence of its being im-
ported from some other country; so the first measure
necessary, is the magistrate's taking care to prevent the
importation: and this may generally be done by a due
attention to bills of health, and to the proper perform-
ance of quarantines.

670. With respect to the latter, we are persuaded,
that the quarantine of persons may safely be much less
than forty days; and, if this were allowed, the execution
of the quarantine would be more exact and certain, as
the temptation to break it would be in a great measure
removed.

671. With respect to the quarantine of goods, it
cannot be perfect, unless the suspected goods be un-
packed and duly ventilated, as well as the other means

* As we do not believe in the communicability of plague, by means of
contagion, it would be superfluous in us to offer any remarks on our au-
thor's mode of prevention, which is founded entirely on that hypothesis.
Considered as a means of accomplishing what he intends, we should only
deny the propriety of the whole. Yet, for the avoidance of a disease arising
from a poison commingled with the atmosphere, many of his directions are
pertinent and useful.

VOL. I. 3 E

402 PRACTICE OF PHYSIC.

employed for correcting the infection they may carry,
and, if all this were properly done, it is probable that
the time commonly prescribed for the quarantine of
goods might also be shortened.

672. A second measure, in the way of prevention,
becomes requisite, when an infection has reached and
prevailed in any place, to prevent that infection from
spreading into other places. This can be done only by
preventing the inhabitants, or the goods of any infected
place, from going out of it, till they have undergone a
proper quarantine.

673. The third measure for prevention, to be em-
ployed with great care, is to hinder the infection from
spreading among the inhabitants of the place in which
it has arisen. The measures necessary for this, are to be
directed by the doctrine laid dowmin 82.", and from that
doctrine we infer, that all persons who can avoid any
near communication with infected persons, or goods,
may escape the infection.

674. For avoiding such communication, a great deal
may be done by the magistrate: 1. By allowing as many
of the inhabitants as are free from the infection, and not
necessary to the service of the place, to go out of it.
2. By prohibiting all assemblies, or unnecessary inter-
course of the people. 3. By taking care that necessary
communications be performed without contact. 4. By
making such arrangements and provisions as may ren-
der it easy for the families remaining to shut themselves
up in their own houses. 5. By allowing persons to quit
houses in which an infection appears, upon condition
that they go into lazarettoes. 6. By ventilating and pu-
rifying, or destroying, at the public expense, all infected
goods. Lastly, by avoiding hospitals, and providing se-
parate apartments for infected persons.

The execution of these measures will require great

PRACTICE OF PHYSIC. 403

authority, and much vigilance and attention, on the part
of the magistrate; but it is not our province to enter
into any detail on this subject of the public police.

675. The fourth and last part of the business of pre-
vention respects the conduct of persons necessarily re-
maining in infected places, especially of those obliged to
have some communication with persons infected.

676. Of those obliged to remain in infected places,
but not obliged to have any near communication with
the sick, they may be preserved from the contagion by
avoiding all near communication with other persons, or
their goods; and it is probable that a small distance will
answer the purpose, if, at the same time, there be no
stream of air to carry the effluvia of persons, or goods,
to some distance.

677. For those who are necessarily obliged to have a
near communication with the sick, it is proper to let
them know, that some of the most powerful contagions
do not operate, but when the bodies of men exposed to
the contagion are in certain circumstances which ren-
der them more liable to be affected by it; and, there-
fore, by avoiding these circumstances and causes, they
may often escape infection.

678. The bodies of men are especially liable to be
affected by contagions, when they are any ways consi-
derably weakened by want of food, and even by a scanty
diet, or one of little nourishment; by intemperance in
drinking, which, when the stupor of intoxication is
over, leaves the body in a weakened state; by excess in
venery; by great fatigue; or by any considerable eva-
cuation.

679. The causes which, concurring with contagion,
render it more certainly active, are cold, fear, and full
living.

The several means, therefore, of avoiding or guard-

101 PRACTICE OF PHYSIC.

ing against the action of cold (94. to, 9G.) arc to be
carefully studied.

680. Against fear the mind is to be fortified as well
as possible, by inspiring a favourable idea of the power
of preservative means; by destroying the opinion of the
incurable nature of the disease; by occupying men's
minds with business or labour; and by avoiding all ob-
jects of fear, as funerals, passing bells, and any notice
of the death of particular friends.

681. A full diet of animal food increases the irritabi-
lity of the body, and favours the operation of conta-
gion; and indigestion, whether from the quantity or qua-
lity of food, has the same effect.

682. Besides giving attention to obviate the several
circumstances (609. 678. to 681.) which favour the
operation of contagion, it is probable that some means
may be employed for strengthening the bodies of men,
and thereby enabling them to resist contagion.

For this purpose, it is probable, that the moderate
use of wine, or of spirituous liquors, may have a good
effect.

It is probable also, that exercise, when it can be em-
ployed, if so moderate as to be neither heating nor
fatiguing to the body, may be employed with advantage.

Persons who have tried cold bathing, and commonly
feel invigorating effects from it, if they are any ways
secure against having already received infection, may
possibly be enabled to resist it by the use of the cold
bath.

It is probable, that some medicines also may be use-
ful in enabling men to resist infection; but amongst
these I can harldy admit the numerous alexipharmics
formerly proposed; or, at least, very few of them, and
those only of tonic power. Amongst these last we
reckon the Peruvian bark; and it is perhaps the

PRACTICE OF PHYSIC. 405

most effectual. If any thing is to be expected from
antiseptics, I think camphire, whether internally or ex-
ternally employed, is one of the most promising.

Every person is to be indulged in the use of any
means of preservation of which he has conceived a
good opinion, whether it be a charm or a medicine, if
the latter be not directly hurtful. (*

Whether issues be useful in preserving from, or in
moderating the effects of contagion, I cannot determine
from the observations I have yet read.

683. As neither the atmosphere in general, nor any
considerable portion of it, is tainted or impregnated
with the matter of contagions; so the lighting of fires
over a great part of the infected city, or other general
fumigations in the open air. are of no use for preventing
the disease, and may perhaps be hurtful.

684. It would probably contribute much to check
the progress of infection, if the poor were enjoined
to make a frequent change of clothing, and were suita-
bly provided for that purpose, and if they were, at the
same time, induced to make a frequent ventilation of
their houses and furniture.

Sect. Ill— Of the Cure of the Plague/"

685. In the cure of the plague, the indications are
the same as those of fever in general (126.); but here
they are not all equally necessary and important.

• To venture on directing the details of practice, in a disease wherein
we have no experience, would betray in us a degree of self-confidence,
wh.ch we do not feel. But, of the general indications, we will venture to
speak

These, from the best view we can take of the disease, appear to be, to
moderate excessive action, or sustain declining strength, according to the
anting state of the system; to evacuate freely the stomach and bowels, en-
deavourmg thus to alter the state of morbid action in the alimentary canal,
and to determine to the surface

406 PRACTICE OF PHYSIC.

686. The measures for moderating the violence oi
reaction, which operate by diminishing the action oi
the heart and arteries (128.), have seldom any place
here; excepting so far as the antiphlogistic regimen is
generally proper. Some physicians, indeed, have re-
commended bleeding-, and there may occur cases in
which bleeding may«be useful ; but, for the most part,
it is unnecessary, and, in many cases, it might be very
hurtful.

Purging has also been recommended; and, in some
degree, it may be useful, in drawing off the bile, or
other putrescent matters, frequently present in the in-
testines; but a large evacuation this way may certainly
be hurtful.

687. The moderating the violence of reaction, so far
as it can be done by taking off the spasm of the ex-
treme vessels, (151.) is a measure of the utmost neces-
sity in the cure of the plague; and the whole of the
means (152. to 200.) suited to this indication are ex-
tremely proper.

688. The giving an emetic at the very first approach
of the disease, would probably be of great service; and
it is likely, that at some other periods of the disease,
emetics might be useful, both by evacuating bile abun-
dant in the alimentary canal, and by taking off the spasm
of the extreme vessels.

To answer these indications, the appropriate remedies must be adminis-
tered. For the two first, suitable evacuations, or stimulants, cordials, and
other articles of nourishment. For the third, vomiting and purging; and,
for the fourth, sudorifics, rubefacients, and blisters, when they can be ap-
plied without endangering the production of gangrene.

The cold bath, when it proves useful in this disease, must do so, by de-
termining to the surface.

Such we believe to be the chief indications for the treatment of plague ;
and such the cardinal remedies to be used in it; which it belongs to the
practitioner to persevere in, or vary, according to the dictates of his judg-
ment, and the result of his experience.

PRACTICE OF PHYSIC. 407

689. From some principles with respect to fever in
general, and with respect to the plague in particular, I
am of opinion, that, after the exhibition of the first vo-
mit, the body should be disposed to sweat; which ought
to be raised to a moderate degree only, but continued
for at least twenty-four hours, or longer if the patient
bear it easily.

690. This sweating should be excited and con-
ducted agreeably to the rules laid down in 168. It is
to be promoted by the plentiful use of diluents, ren-
dered more grateful by vegetable acids, or more pow-
erful by being impregnated with some portion of neu-
tral salts.

691. To support the patient under the continuance
of the sweat, a little weak broth, acidulated with the
juice of lemons, may be given frequently; and some-
times a little wine, if the heat of the body be not con-
siderable.

692. If sudorific medicines are judged to be neces-
sary, opiates are the most effectual and safe: but they
should not be combined with aromatics; and probably
may be more effectual if joined with a portion of emetics,
and of neutral salts.

693. If, notwithstanding the use of emetics and su-
dorifics, the disease should still continue, the cure
must depend upon the employment of means for obvi-
ating debility and putrescency; and for this purpose,
the various remedies proposed above, (from 201. to
221.) may all be administered, but especially the to-
nics; and of these the chief are cold drink and the Pe-
ruvian bark.

694. In the cure of the plague, some attention is
due to the management of buboes and carbuncles; but
we do not touch this, as it belongs to the province of
surgery.

408 PRACTICE OF PHYSK

CHAPTER VI.

OF ERYSIPELAS, OR ST. ANTHONY'S FIRE.

695. IN 274, I mentioned the distinction which I pro-
posed to make between the diseases to be named the
Erythema and the Erysipelas; and from thence it will
appear that Erysipelas, as an Erythema following fever,
may have its place here.

696. I suppose the Erysipelas to depend on a mat-
ter generated within the body, and which, analogous to
the other cases of exanthemata, is in consequence of fe-
ver thrown out upon the surface of the body. I own
it may be difficult to apply this to every particular case
of Erysipelas: but I take the case in which it is gene-
rally supposed to apply, that of the Erysipelas of the
face; which I shall therefore consider here.*

* This, like most other diseases of the skin, appears to have its seat in the
stomach. At the commencement of erysipelas of the face, that organ is
known to be oftentimes very much affected. Hence, the free evacuation of
the alimentary canal is a measure of great importance, in the treatment of
that disease.

Erysipelas of the face, moreover, possesses many points of strong resem-
blance to gout. In fact, it is oftentimes nothing but a modification of gout;
which, as we have already represented, has its origin in the stomach.

Some of the points of resemblance between gout and erysipelas of the
face are, that these diseases occur, not only in subjects of the same descrip-
tion, but in the same individuals, and even, occasionally, alternate with each
other. We are intimate with a gentleman, of a gouty diathesis, whose pa-
roxysms have several times commenced in the form of erysipelas of the
face, and terminated in regular podagra. Other instances of the same kind
we know to have occurred.

Females, about the termination of their menstrual period, are particularly
liable to erysipelas of the face. In them, we believe it to be, oftentimes, at
least, nothing but a substitute for another form of gout

Impressed by these considerations, we cannot but regard it as a very pal-
pable error in Dr. Cullen, to have introduced erysipelas into his order exan-
themata. It undoubtedly belongs to that of phlegmasiw, as the professor
himself finds cause to acknowledge.

PRACTICE OF PHYSIC. 409

097. The Erysipelas of the face comes on with a cold
shivering, and other symptoms of the pyrexia. The hot
stage of this is frequently attended with a confusion of
head and some degree of delirium; and almost always
with drowsiness, and perhaps cOma. The pulse is al-
ways frequent, and commonly full and hard.

G98. When these symptoms have continued for one,
two, or at most three days, there appears, on some
part of the face, a redness, such as that described in
215. as the appearance of Erythema. This redness,
at first, is of no great extent; but gradually spreads from
the part it first occupied to the other parts of the face,
commonly till it has affected the whole; and frequently
from the face it spreads over the hairy scalp, or de-
scends on some part of the neck. As the redness
spreads, it commonly disappears, or at least decreases,
in the parts it had before occupied. All the parts upon
which the redness appears are, at the same time, affected
with some swelling, which continues for some time after
the redness has abated. The whole face becomes con-
siderably turgid; and the eye-lids are often so much
swelled as entirely to shut up the eyes.

699. When the redness and swelling have proceeded
for some time, there commonly arise, sooner or later,
blisters of a larger or smaller size, on several parts of
the face. These contain a thin yellowish, or almost
colourless liquor, which sooner or later runs out. The
surface of the skin, in the blistered places, sometimes
becomes livid and blackish; but this livor seldom goes
deeper than the surface, or discovers any degree of gan-
grene affecting the skin. On the parts of the face not
affected with blisters, the cuticle suffers, towards the
end of the disease, a considerable desquamation. Some-
times the tumour of the eye-lids ends in a suppuration.

700. The inflammation coming upon the face does
vol. i. 3 F

UO PRACTICE OF PHYSIC.

not produce any remission of the fever which had be-
fore prevailed; and sometimes the fever increases with
the increasing and spreading inflammation.

701. The inflammation usually continues for eight or
ten days; and, for the same time, the fever and symp-
toms attending it also continue.

702. In the progress of the inflammation the delirium
and coma attending it sometimes go on increasing, and
the patient dies apoplectic on the seventh, ninth, or
eleventh day of the disease. In such cases it has been
commonly supposed that the disease is translated from
the external to the internal parts. But I have not seen
any instance in which it did not appear to me, that the
affection of the brain was merely a communication of
the external affection, as this continued increasing at
the same time with the internal.

703. When the fatal event does not take place, the
inflammation, after having affected a part, commonly
the whole of the face, and perhaps the other external
parts of the head, ceases. With the inflammation, the
fever also ceases; and without any evident crisis, the pa-
tient returns to his ordinary state of health.

704. This disease is not commonly contagious; but
as it may arise from an acrid matter externally applied,
so it is possible that the disease may sometimes be com-
municated from one person to another.

Persons who have once laboured under this disease
are liable to returns of it*

705. The event of this disease may be foreseen from
the state of the svmptoms, which denote more or less
affection of the brain. If neither delirium nor coma
come on, the disease is seldom attended with any dan-
ger; but when these symptoms appear early in the dis-

* This disease does not exhibit a mark of contagion more than intermitting
. rheumatism, or peripneumony.

PRACTICE OF PHYSIC. 411

ease, and are in a considerable degree, the utmost dan-
ger is to be apprehended.

706. As this disease often arises in the part, at the
same time with the coming on of the pyrexia; as I have
known it, with all its symptoms, arise from an acrimony
applied to the part; as it is commonly attended with a
full and frequently a hard pulse; as the blood drawn in
this disease shows the same crust upon its surface, that
appears in the phlegmasia?; and, lastly, as the swelling
of the eye-lids, in this disease, frequently ends in suppu-
ration; so, from these considerations, it seems doubtful
if this disease be properly, in Nosology, separated from
the Phlegmasia?. At any rate, I take the disease I have
described to be what physicians have named the Ery-
sipelas Phlegmonodes, and that it partakes a great deal
of the nature of the Phlegmasia?.

707. Upon this conclusion, the Erysipelas of the face
is to be cured very much in the same maimer as phleg-
monic inflammation, by blood-letting, cooling purgatives,
and by employing every part of the antiphlogistic regi-
men; and our experience has confirmed the fitness of
this method of cure.

708. The evacuations of blood-letting and purging are
to be employed more or less, according to the urgency
of symptoms, particularly those of the pyrexia, and of
those which mark an affection of the brain. As the
pyrexia continues and often increases with the inflam-
mation of the face, so the evacuations mentioned may
be employed at any time in the course of the disease.*

709. In this, as in other diseases of the head, it is

* Copious purging is a most important remedy in this disease. So is
blood-letting, carried, in many instances, to a considerable extent, and seve-
ral times repeated. In very threatening cases, nearly a hundred ounces of
bloo.l have been taken away, in a few days, with great advantage. Usually,
however, the quantity necessary to be drawn is much less.

412 PRACTICE OF PHYSIC.

proper to put the patient, as often as he can easily bear
it, into somewhat of an erect posture*

710. As in this disease there is always an external
affection, and as in many instances there is no other;
so various external applications to the part affected
have been proposed; but almost all of them are of doubt-
ful effect. The Narcotic, refrigerant, and astringent
applications, are suspected of disposing to gangrene;
spirituous applications seem to increase the inflamma-
tion; and all oily or watery applications seem to occa-
sion its spreading. The application that seems most
safe, and which is now most commonly employed, is
that of a dry mealy powder frequently sprinkled upon
the inflamed parts.f

711. An Erysipelas Phlegmonodes frequently ap-
pears on other parts of the body, beside the face; and
such other erysipelatous inflammations frequently end
in suppuration. These cases are seldom dangerous.
At coming on, they are sometimes attended with drow-

* It is advisable to keep the head of the patient somewhat elevated in this
complaint — as much so, at least, as is agreeable to his feelings: but, in no
dangerous febrile affection, can an erect posture of the body be either useful
or admissible. In such a case, the stimulus of muscular exertion should be
carefully avoided. In laying down his antiphlogistic plan of treatment, Dr.
Cullen himself very properly gives a particular and strong injunction to this
effect.

| A very common and grateful application in this disease, is that of oat-
meal or rye-flour, frequently repeated. It is to be lightly sprinkled on the
part, and when it becomes warm, carefully wiped off and renewed. It allays
the itching and burning, which are so troublesome and distressing, and com-
municates an agreeable sensation of coolness.

But nothing, we believe, so effectually checks the progress o'f erysipela-
tous inflammation, as the use of blisters. When the inflamed spot is so situ-
ated, and of such a size, that it can be completely covered by a blister, it
rarely extends any further.

In erysipelas of the face we have never employed this remedy. But, for
arresting the course of this disease, v.'hcn affecting other parts of the body,
we have repeatedly used it, with great advantage. In what our author de-
nominates "erysipelas phlegmonodes" of the limbs, it should never be ne
gjectedi

PRACTICE OF PHYSIC. £1$

siness, and even with some delirium; but this rarely
happens; and these symptoms do not continue after the
inflammation is formed. I have never seen an instance
of the translation of this inflammation from the limbs
to an internal part; and though these inflammations of
the limbs be attended with pyrexia, they seldom require
the same evacuations as the erysipelas of the face. At
first they are to be treated by dry mealy applications
only; and all humid applications, as fomentations, or
poultices, are not to be applied, till, by the continuance
of (he disease, by the increase of swelling, or by a
throbbing felt in the part, it appears that the disease is
proceeding to suppuration.

712. We have hitherto considered erysipelas as in
a great measure of a phlegmonic nature; and agreeably
to that opinion, we have proposed our method of cure.
But it is probable, that an erysipelas is sometimes at-
tended with, or is a symptom of, a putrid fever; and, in
such cases, the evacuations proposed above may be im-
proper, and the use of the Peruvian bark may be neces-
sary; but I cannot be explicit upon this subject, as such
putrid cases have not come under my observation.

CHAPTER VII.
OF THE MILIARY FEVER.*

713. 1 HIS disease is said to have been unknown to
the ancients, and that it appeared, for the first time, in

• Very fortunately, the form of fever treated of in this chapter is but little
known in the United States. We are yet to be convinced that it is knowfl
at all. As to ourselves, we do not recollect ever to have seen a decided
case ef it. With our author, we are apprehensive that it is always the re
wit of injudicious treatment. It arises from the action of an excess

414 PRACTICE OF PHYSIC.

Saxony, about the middle of the last century. It is
said to have spread from thence into all the other parts

ternal heat, and internal stimulants— more especially the latter: for, like
other diseases of the skin, it is of gastric origin. To the alexipharmic and
heating regimen generally, once so fashionable in the treatment of fever, in
Europe, but which never found its way, in strength, across the Atlantic, is
(he existence of this complaint to be chiefly attributed. That regimen was
pursued more especially in the case of lying-in women, and hence the rea-
son, why these subjects were most liable to miliary fever. Even among
ourselves, and, at the present day, females, in this situation, are frequently
injured by the use of an inflammatory preparation denominated caudle.

We have seen eruptions of the miliary kind produced by an indiscreet
and extravagant use of pepper mixed in ardent spirits, for the cure of inter-
mitting fever. Large and repeated doses of spirits of turpentine have been
known to be productive of a similar effect. Even the bark itself, unskilfally
administered, during the existence of fever, has often given rise to cuta-
neous eruptions. About the mouth, these eruptions are by no means un-
common, and are precursory, for the most part, to the disappeaitnce of the
complaint.

The perspirable matter, confined on the skin, by an excess of covering,
stimulates by its acrimony, and aids in the production of the disease we are
considering.

When the miliary fever does occur, we believe, with our author, that the
propertreatment of it consists in a cooling regimen ; to which should be add-
ed, provided the patient's strength be sufficient to bear it, the use of
emetics and active purgatives. But the proper practice is, to prevent this
disease, by an avoidance of the causes which are known to produce it — a
measure, for the neglect of which, we are altogether inexcusable, in as much
as those causes are perfectly under our control. We feel persuaded, that
at no very distant period, when the treatment of diseases shall be conducted
on more enlightened and rational principles, miliary fever will be recog-
nized only by name, as a memorial of the errors of earlier times.

Among the multiplied forms and varieties of epidemics, it is altogether
possible, that some may appear, marked by extensive miliar}' eruptions, in-
dependently of the influence of the causes we have enumerated. In case of
the occurrence of such an event, the disease will be found to be of gastric
origin, and the principal remedies in the treatment of it, will be, vomiting,
purging, and, perhaps, blood-letting. The complaint may, however, as-
sume a typhous character, when the latter remedy will, of course, be inad-
missible.

A superabundant acidity in the stomach proves sometimes the cause of,
or at least, accompanies, cutaneous eruptions. In this case, alkalis and ab-
sorbents are useful remedies Tonics must also be administered, to remove
the weakness and want of digestive power, from which the acidity arises.

If, in miliary fever, a retrocession of the eruption take place or be
strongly threatened, sudorifics and blisters are the remedies by which the
evil should be met. In this case, cold and, perhaps* even cool air should be

PRACTICE OF PHYSIC. 415

of Europe; and, since the period mentioned, to have
appeared in many countries in which it had never ap-
peared before.

714. From the time of its having been first particu-
larly observed, it has been described and treated of by
many different writers; and by all of them, till very late-
ly, has been considered as a peculiar idiopathic disease.

It is said to have been constantly attended with pe-
culiar symptoms. It comes on with a cold stage, which
is often considerable. The hot stage which succeeds,
is attended with great anxiety, and frequent sighing.
The heat of the body becomes great, and soon pro-
duces profuse sweating; preceded, however, by a sense
of pricking, as of pin-points in the skin; and the sweat
is of a peculiarly rank and disagreeable odour. The
eruption appears sooner or later in different persons,
but at no determined period of the disease. It seldom
or never appears on the face; but discovers itself first
upon the neck and breast, and from thence often
spreads over the whole body.

715. The eruption named Miliary is said to be of
two kinds, the one named the Red, the other the White
Miliary. The former, which in English is strictly named
the Rash, is commonly allowed to be a symptomatic af-
fection; and as the latter is the only one that has any
pretensions to be considered as an idiopathic disease, it
is this alone that I shall more particularly describe and
treat of in the present chapter.

carefully avoided. An emetic may avert or remove the mischief, by alter-
ing the condition of the stomach — the probable cause of the retrocession —
and determining to the surface. Convulsions, under these circumstances,
must be extremely dangerous. If they occur, bleeding, blistering and in-
jections will be necessary. Perhaps an anodyne injection may afford relief,
as it frequently does in convulsions from other causes.

With these remarks we dismiss the subject, leaving to our readers to ac-
quire a knowledge of the history of miliary fever from the text of our au-
thor.

ilG PRACTICE OF PHYSIC.

716. What then is called the White Miliary eruption
appears at first like the red, in very small red pimples,
for the most part distinct, but sometimes clustered to-
gether. Their slight prominence is distinguished better
by the finger than by the eye. Soon after the appear-
ance of this eruption, and at least on the second day,
a small vesicle appears upon the top of each pimple.
At first the vesicle is whey-coloured; but soon becomes
white, and stands out like a globule on the top of the
pimple. In two or three days, these globules break, or
are rubbed off; and are succeeded by small crusts,
which soon after fall off in small scales. While one set
of pimples takes this course, another set succeeds; so
that the disease often continues upon the skin for many
days together. Sometimes when one crop of this erup-
tion has disappeared, another, after some interval, is
produced. And it has been further observed, that in
some persons there is such a tendency to this disease,
that they have been affected with it several times, in the
course of their lives.

717. This disease is said to affect both sexes, and
persons of all ages and constitutions; but it has been
observed, at all times, to affect especially, and most fre-
quently, lying-in women.

718. This disease is often accompanied with violent
symptoms, and has frequently proved fatal. The symp-
toms attending it are, however, very various. They are,
in one or other instances, all the several symptoms at-
tending febrile diseases; but I cannot find that any symp-
tom or course of symptoms are steadily the same in dif-
ferent persons, so as to furnish any specific character to
the disease. When the disease is violent, the most com-
mon symptoms are phrenitic, comatose, and convulsive
affections, which are also symptoms of all fevers treated
by a very warm regimen.

PRACTICE OF PHYSIC. 417

719. While there is such a variety of symptoms ap-
pearing in this disease, it is not to be expected that any
one particular method of cure can be proposed: and ac-
cordingly we find, in different writers, different methods
and remedies prescribed; frequent disputes about the
most proper; and those received and practised by some,
opposed and rejected by others.

720. I have thus given an account of what I have
found delivered by authors who have considered the
white miliary fever as an idiopathic disease: but, now,
after having often observed the disease, I must say that
I doubt much if it ever be such an idiopathic, as has
been supposed, and I suspect that there is much fallacy
in what has been written on the subject.

721. It seems to me very improbable, that this should
have been really a new disease when it was first con-
sidered as such. There appear to me very clear traces
of it in authors who wrote long before that period; and,
though there were not, we know that the descriptions
of the ancients were inaccurate and imperfect, particu-
larly with respect to cutaneous affections; whilst we
know also very well, that those affections which usually
appear as symptomatic only, were commonly neglected,
or confounded together under a general appellation.

722. The antecedent symptoms of anxiety, sighing,
and pricking of the skin, which have been spoken of as
peculiar to this disease, are, however, common to many
others; and, perhaps to all those in which sweatings are
forced out by a warm regimen.

Of the symptoms said to be concomitant of this erup-
tion, there are none which can be said to be constant and
peculiar but that of sweating. This, indeed, always pre-
cedes and accompanies the eruption; and, while the
miliary eruption attends many different diseases, it ne-
ver, however, appears in any of these, but after sweat-

vol. i. 3 G

418 PRACTICE OF PHYSIC.

ing; and, in persons labouring under these diseases, it
does not appear, if sweating be avoided. It is tin
fore probable, that the eruption is the effect of sweat-
ing; and that it is the produce of a matter, not before
prevailing in the mass of blood, but generated, under
particular circumstances, in the skin itself. That it
depends upon particular circumstances of the skin, ap-
pears further from hence, that the eruption seldom or
never appears upon the face, although it affects the
whole of the body besides; that it comes upon those
places especially which are more closely covered; and
that it can be brought out upon particular parts by ex-
ternal applications.

723. It is to be observed, that this eruptive disease
differs from the other exanthemata in many circum-
stances; in its not being contagious, and therefore ne-
ver epidemic; that the eruption appears at no deter-
mined period of the disease; that the eruption has no
determined duration; that successive eruptions fre-
quently appear in the course of the same fever; and that
such eruptions frequently recur in the course of the
same person's life.

All these circumstances render it extremely probable,
that, in the miliary fever, the morbific matter is not a
subsisting contagion communicated to the blood, and
thence, in consequence of fever and assimilation, thrown
out upon the surface of the body; but a matter occa-
sionally produced in the skin itself, by sweating.

724. This conclusion is further rendered probable,
from hence, that, while the miliary eruption has no pe-
culiar symptoms, or concourse of symptoms, belonging
to it; yet, upon occasion, it accompanies almost all fe-
brile diseases, whether inflammatory or putrid, if these
happen to be attended with sweating; and from thence
it may be presumed^ that the miliary eruption is a symp

PRACTICE OF PHYSIC. 419

tomatic affection only, produced in the manner we have
said.

125. But, as this symptomatic affection does not al-
ways accompany every instance of sweating, it may be
proper to inquire what are the circumstances which es-
pecially determine this eruption to appear? To this,
however, I can give no full and proper answer. I can-
not say that there is any one circumstance which in all
cases gives occasion to this eruption; nor can I say, what
different causes may, in different cases, give occasion
to it. There is only one observation I can offer to the
purpose of this inquiry; and it is, that, of the persons
sweating under febrile diseases, those are especially lia-
ble to the miliary eruption, who have been previously
weakened by large evacuations, particularly of blood.
This will explain why it happens to lying-in women
more frequently than to any other persons; and to con-
firm this explanation, I have remarked, that the eruption
happened to women not in child-bed, but who had been
much subjected to a frequent and copious menstruation;
and to an almost constant fluor albus. I have also had
occasion to observe it happen to men in fevers, after
wounds from which they had suffered a great loss of
blood.

Further, that this eruption is produced by a certain
state of debility, will appear probable, from its often oc-
curring in fevers of the putrid kind, which are always
attended with great debility. It is true, that it also
sometimes attends inflammatory diseases, when it cannot
be accounted for in the same manner; but I believe it
will be found to attend especially those inflammatory
diseases in which the sweats have been long protracted
or frequently repeated, and which have thereby pro-
duced a debility, and perhaps a debilitating putrid dia-
thesis.

1,20 PRACTICE OF PHYSIC.

726. It appears so clearly to me, that this eruption
is always a symptomatic and factitious affection, that
I am persuaded it may be in most cases prevented
merely by avoiding sweats. Spontaneous sweatings, in
the beginning of diseases, are very rarely critical; all
sweatings, not evidently critical, should be prevented;
and the promoting them, by increasing external heat,
is commonly very pernicious. Even critical sweats
should hardly be encouraged by such means. If, there-
fore, spontaneous sweats arise, they are to be checked
by the coolness of the chamber; by the lightness and
coolness of the bed-clothes; by the person's laying out
their hands and arms, and by their taking cold drink:
and, by these precautions, I think I have frequently
prevented miliary eruptions, which were otherwise like-
ly to have appeared, particularly in lying-in women.

727. But it may happen, when these precautions
have been neglected, or from other circumstances, that
a miliary eruption does actually appear; and the ques-
tion will then be put, how the case is to be treated? It
is a question of consequence, because I believe that
the matter here generated is often of a virulent kind;
it is frequently the offspring of putrescency^ and, when
treated by increasing the external heat of the body, it
seems to acquire a virulence which produces those
symptoms mentioned in 718, and proves certainly fatal.

It has been an unhappy opinion with most physicians,
that eruptive diseases were readily to be hurt by cold;
and that it was, therefore, necessary to cover up the
body very closely, so as thereby to increase the external
heat. We now know that this is a mistaken opinion;
that increasing the external heat of the body is very
generally mischievous; and that several eruptions not
only admit, but require the application of cold air. We
are now persuaded, that the practice which formerly

PRACTICE OF PHYSIC. 421

prevailed, in the case of miliary eruptions, of covering
up the body close, and, both by external means, and
internal remedies, encouraging the sweatings which ac-
company this eruption, was highly pernicious, and
commonly fatal. I am, therefore, of opinion, even
when a miliary eruption has appeared, that in all cases
where the sweating is not manifestly critical, we should
employ all the several means of stopping it that are
mentioned above; and I have sometimes had occasion
to observe, that even the admission of cool air was safe
and useful.

728. This is, in general, the treatment of miliary
eruptions; but, at the same time, the remedies suited
to the primary disease, are to be employed: and, there-
fore, when the eruption happens to accompany inflam-
matory affections, and when the fulness and hardness
of the pulse or other symptoms show an inflammatory
state present, the case is to be treated by blood-letting,
purging, and other antiphlogistic remedies.

Upon the other hand, when the miliary eruption at-
tends diseases in which debility and putrescency pre-
vail, it will be proper to avoid all evacuations, and
employ tonic and antiseptic remedies, particularly the
Peruvian bark, cold drink, and cold air.

I shall conclude this subject with mentioning, that
the venerable octogenarian practitioner, de Fischer,
when treating of this subject, in laying down the indi-
cations of cure, has given this as one of them: " Excre-
tionis periphericae non primariain habere rationem."

122 PRACTICE OF PHYSIC.

CHAPTER VIII.

OF THE REMAINING EXANTHEMATA,
URTICARIA, PEMPHIGUS, AND APHTHA.*

729. THE Nettle Rash is a name applied to two dif-
ferent diseases. The one is the chronic eruption de-

* Although every malady is an evil which ought to be carefully prevented
or removed, yet the diseases treated of in this chapter are, comparatively,
of little moment.

Of Pemphigus we have no knowledge, having never seen the complaint
ourselves, nor read any account of it that is worthy of being remembered,
much less reprinted. We shall, therefore, dismiss it without further notice.
In the mean time, those who are curious on the subject, may consult Wil-
lan, Dickson, (Transactions of the Royal Irish Academy for 1787,) and
Thomas; from each of whom something may be learnt respecting this dis-
ease. Although but little known in Europe, it is still, we believe, a much
greater stranger in the United States.

Urticaria, or Nettle-rash, has a place among the diseases of our country;
but so mild is it in its nature, and so inconsiderable are the danger and in-
convenience which accompany it, that physicians are but rarely consulted re-
specting its treatment.

It is more particularly a disease of youth, and occurs most frequently in
the season of spring. The returning warmth of the atmosphere may have
some influence in producing it; but most cases of it that we have witnessed,
could be clearly traced to gastric irritation. We once saw it brought on by
a diet of rich chocolate, in a youth who had just recovered from a severe
attack of inflammatory fever. In other instances, we have been able to trace
it to an immoderate use of pickles, spices, and acids. We lately attended
an irregular case of it in a child of about four years old, which had been
evidently induced by an inordinate meal of sour cherries.

When it calls for remedies, the first and principal indication in the treat-
ment of it is, to evacuate thoroughly the alimentary canal. This must be
done by vomiting and purging. A solution of tartarized antimony and sul-
phate of soda, constitutes, for this purpose, a valuable remedy. The for-
mula is, an ounce of the latter, added to two or three gains of the former, to
be exhibited in divided doses till it operate.

If the disease, which is always, we believe, inflammatory, yield not to re-
medies directed to the alimentary canal, we must resort to blood-letting. It
is understood, that during our treatment of it, a strict observance of the an-
tiphlogistic regimen is to be enjoined — in a more especial manner, an avoid-

PRACTICE OF PHYSIC, 403

scribed by Dr. Heberden in the Medical Transactions,
vol. i. art. xvii. which, as not being a febrile disorder,

ance of every thing that might irritate the stomach. The termination of
Urticaria is always favourable.

Aphtha or Thrush, commences also, we believe, in the stomach. In this
country, it is very much a disease of childhood; although cases of it do
occur in adults, whose stomach and bowels are irritable and weak. An epi-
demic aphthous fever has nerer, to our knowledge, appeared in the United
States. In Barbadoes, and others of the West India islands, adults are often-
times attacked by it, with a degree of violence and obstinacy, which nothing
but a change of climate can overcome. In Holland, Zealand, and other low
and humid countries of the north of Europe, it is very common ; while in
the warm and dry countries of the south, it is scarcely known.

In this disease the eruptions generally make their appearance first about
the angles of the lips, whence they spread to the inside of the lips, the
tongue, the fauces, the oesophagus, and the whole alimentary canal ; until
they ultimately appear even without the anus. Their colour varies, from
■white to yellow, and from yellow to brown. The latter colour indicates
danger.

The eruptions about the mouth, although sometimes preceded by fever,
are generally, we believe, the elder symptom. Morbid irritation in the
stomach and bowels always precedes the fever, and acts as its cause.

Aphtha, by attacking the gums of children, sometimes produces a general
caries of the teeth. This manifests the existence of a strong sympathetic
connection between the teeth and the stomach — a position which we endea-
voured to establish in our annotations on odontalgia.

In the treatment of aphtha, the cleansing of the stomach and bowels, by
emetics and cathartics, should constitute the first object of attention. As
the natural tendency of the disease, however, is to diarrhoea, the drastic pur-
gatives are of doubtful utility. Castor oil, rhubarb, magnesia, and some of
the milder saline purgatives, are generally employed. Calomel is also ex-
hibited, either alone or in combination with rhubarb, and proves, in many
cases, a very valuable remedy. The cases wherein it is used being well se-
lected, sve think it among the most useful that can be administered.

It is in the commencement of the disease, before the aphthous eruption
has passed into the stomach and bowels, that these remedies may be most
usefully employed. During its whole continuance, however, the prima; viae
must be kept free from irritating contents : for if, by their morbific impres-
sion, such contents originally produce the complaint, they must certainly
aggravate it, and render it more obstinate, when it is already in existence.
But, when the disease is at its height, injections are recommended in pre-
ference to cathartics administered by the mouth. The reason assigned is,
the clanger of inducing, by the use of purgatives, a debilitating and unmanage-
able hypercatharsis.

Towards the close of the disease, when the aphthous crusts are beginning
to fall off, purgatives are again recommended, with a view to their removal
from the alimentary canal.

424 PRACTICE OF PHYSIC.

does not belong to this place. The other is the Urti
caria of our Synopsis, which, as taken into every sys-
tem of Nosology as one of the Exanthemata Febrilia, is
properly to be treated of here.

730. I have never observed this disease as contagious
and epidemic; and the few sporadic cases of it which
have occurred to me, have seldom taken the regular
course described by authors. At the same time, as the
accounts of different authors are not very uniform, and
hardly consistent, I cannot enter further into the consi-
deration of this subject: and I hope it is not very neces-
sary, as on all hands it is agreed to be a mild disease,
and such as seldom requires the use of remedies. It is
generally sufficient to observe an antiphlogistic regimen,
and to keep the patient in a temperature that is neither
hot nor cold.

731. The Pemphigus, or Vesicular Fever, is a rare
and uncommon disease, and very few instances of it are
recorded in the writings of physicians. As I have never
had occasion to see it, it would be improper for me to
treat of it; and I do not choose to repeat after others,
while the disease has yet been little observed, and its

As the alimentary canal is known to sympathize very powerfully with the
skin, gentle diaphoretics are advantageously administered in the treatment
of aphtha.

Magnesia, as an absorbent and gentle evacuant, is also recommended as
particularly useful. It not only neutralizes the acid which usually super-
abounds in the prima: vise, but converts it into a means of removing from
the bowels what, would otherwise prove offensive.

The diet should be nutritive, but entirely liquid, mucilaginous, and mild
It may consist of well boiled sago, tapioca, powdered arrow-root, or barley
water. Flax-seed tea ami gum arable dissolved in water make suitable
drinks.

As milk of bad qualities contributes to the production of aphtha in infants,
fresh and wholesome milk, on the other hand, constitutes, when the fever ia
not too violent, an exceedingly valuable article of diet.

Those readers who wish to be more fully informed on the subject of this
disease, are referred to Dr. Wilson's able and elaborate article on " aphthous
fever."

PRACTICE OF PHYSIC. 425

character does not seem to be exactly ascertained.
Vid. Acta Helvetica, vol. ii. p. 260. Synops. Nosolog.
vol. ii. p. 149.

732. The Aphtha, or Thrush, is a disease better
known; and, as it commonly appears in infants, it is so
well understood, as not to need our treating of it here.
As an idiopathic disease, affecting adults, I have not
seen it in this country: but it seems to be more frequent
in Holland; and, therefore, for the study of it, I refer
to Dr. Boerhaave, and his commentator Van Swieten,
whose works are in every body's hands.

733. The Petechia has been, by all our Nosologists,
enumerated amongst the exanthemata; but as, accord-
ing to the opinion of most physicians, it is very justly
held to be always a symptomatic affection only, I can-
not give it a place here.

vol. i. 3 H

126 PRACTICE OF PHYSIC.

BOOK IV.

OF BUEMORKHAGIES.

CHAPTER I.
OF FLEMORRFIAGY IN GENERAL.

734. IN establishing a class or order of diseases under
the title of Hcemorrhagics, Nosologists have employed
the single circumstance of an effusion of red blood, as
the character of such a class or order. By this means
they have associated diseases which in their nature are
very different; but, in every methodical distribution,
such arbitrary and unnatural associations should be
avoided as much as possible. Further, by that manage-
ment Nosologists have suppressed or lost sight of an
established and well-founded distinction of hamiorrha-
gies into Active and Passive.*

* The division of Haemorrhagies into " active and passive," recognized by
our author in this article, is utterly unfounded, and ought to be rejected
from pathological science. The phraseology leads to a physiological error.
The expression "passive haemorrhagy," as applied to living matter, is a
gross misnomer. During life, no haemorrhagy can possibly be passive.
Blood flows from the vessel that contains it, at least in part, by means of the
action of that vessel. Nor is it possible for such action to cease, otherwise
than by the cessation of life in the part. But the cessation of life is the
■commencement of gangrene. A haemorrhagy really passive, therefore, can-
not take place except from gangrenous vessels. But from such vessels,
unless they be very large, blood does not flow at all. The reason is obvious.
They act on the blood which they contain like dead matter : and we well
know that the action of dead matter on blood forces it to coagulate. Hence,
in the vessels of a gangrenous part, the blood does coagulate, and prevents
the hjemorrhagy that would otherwise ensue.
Every haemorrhagy, therefore, that does or can take place from the living

PRACTICE OF PHYSIC. 427

735. It is my design to restore this distinction; and
I shall therefore here, under the title of Haemorrhages,
comprehend those only which have been commonly
called Active, that is, those attended with some degree
of pyrexia; which seem always to depend upon an in-
creased impetus of blood in the vessels pouring it out,
and which chiefly arise from an internal cause. In this
I follow Dr. Hoffman, who joins the active haemorrha-
gies with the febrile diseases, and have accordingly
established these hagmorrhagies as an order in the
class of Pyrexia. From this order I exclude all those
effusions of red blood that are owing entirely to exter-
nal violence; and all those which, though arising from
internal causes, are however not attended with pyrexia,
and which seem to be owing to a putrid fluidity of the
blood, to the weakness or to the erosion of the vessels,
rather than to any increased impetus of the blood in
them.

736. Before proceeding to treat of those proper hae-
morrhagies which form an order in our Nosology, I
shall treat of active hasmorrhagy in general; and indeed
the several genera and species to be treated of particu-
larly afterwards have so many circumstances in corn-

body, is really an active one. It arises, not from the absolute want of action,
in the part ; but from its wrong action. The vessels dilate, or rather con-
tract and dilate alternately, when they ought to contract only, and thus pre-
vent the escape of the blood which they contain.

But some hxmorrhagies are attended with more action than others.
Some have a much more general aspect than others. Some are febrile,
others not.

Instead, then, of being denominated active and passive, they might, in
our estimation, be much more correctly divided into tonic and atonic- or, if
we might be permitted to coin terms more suitable to the occasion, into
pyrectic and apyrcctic-

Tonic or pyrectic hxmorrhagy appears to be the very reverse of inflam-
mation The latter consists in a deficiency, the former in an excess, of ac-
ion in 'ho ypsseNof the part affected.

1-28 PRACTICE OF PHYSIC.

inon with one another, that the genera] consideration
to be now offered will prove both proper and useful.

Sect. I. — Of the Phenomena of Hcemorrhagy.

737. The phenomena of haemorrhagy arc generally
the following.

Haemorrhagies happen especially in plethoric habits,
and to persons of a sanguine temperament. They ap-
pear most commonly in the spring, or in the beginning
of summer.

For some time, longer or shorter in different cases,
before the blood flows, there are some symptoms of
fulness and tension about the parts from whence the
blood is to issue. In such parts as fall under our view,
there are some redness, swelling and sense of heat or of
itching ; and in the internal parts from which blood is to
flow, there is a sense of weight and heat; and, in both
cases, various pains are often felt in the neighbouring
parts.*

738. When these symptoms have subsisted for some
time, some degree of a cold stage of pyrexia comes on,
and a hot stage is formed; during which, the blood
flows of a florid colour, in a greater or lesser quantity,
and continues to flow for a longer or shorter time; but
commonly, after some time, the effusion spontaneously
ceases, and together with it the pyrexia also.

739. During the hot stage which precedes an hae-
morrhagy, the pulse is frequent, quick, full, and often
hard; but as the blood flows, the pulse becomes softer
and less frequent.

740. In ha3morrhagies, blood drawn from a vein does,

* To the symptoms announcing the approach of haemorrhagy from any
part of the body, our author should have added, a sense of throbbing, or pul-
sation, in the vessels from which the blood is to flow.

PRACTICE OF PHYSIC. 429

upon its concreting, commonly show the gluten sepa-
rated, or a crust formed, asin the cases of Phlegmasia?.
741. Haemorrhagies from internal causes, having
once happened, are apt, after a certain interval, to re-
turn-, in some cases very often, and frequently at stated
periods*

* That haemorrhagies recur periodically, is a fact, which will not, we pre-
sume, be, at present, called in question. Nor is it, in reality, less true, al-
though a matter of much less notoriety, that such recurrence corresponds
very accurately, at least in many instances, to the periods of the moon.

For no inconsiderable amount of curious information on this subject, our
readers are referred to the writings of Dr Mead ; particularly his well
known and very learned treatise, " De imperio Solis el Lun<e."

To the more recent writings of Dr. Moseley, we are also indebted foP
much information touching the influence of the moon on hxmorrhagies

" The haemorrhagies from the lungs," says this author, " or those of ple-
thora, like all periodical haemorrhagies, undisturbed in their natural course
by peculiar circumstances, obey the influence of the moon. Of this I have
many proofs ; and that there are not more, authenticated by others, is owing,
I believe, to the theory on which the fact depends not being sufficiently
known to prevent the result escaping unnoticed.

"Among the many instances which I have lately seen, there was one
which deserves to be recorded. A man in Burleigh-street, in the Strand,
had a cough for some time, which brought on a haemoptysis. This continued
for six weeks, and then degenerated into a regular monthly eruption of
blood from the lungs. He disgorged about eight ounces of blood from the lungs
every full moon.

" This doctrine attended to," continues our author, " haemorrhagies
which do not prove fatal in the first or second attack, will seldom be
so afterwards; as their returns may always be moderated, and often en-
tirely prevented; which, from repeatedly wounding the lungs, induce ulce-
ration there, and end the subject in consumption."

In further confirmation of the doctrine of the influence of the moon in the
production of haemorrhagies, Dr. Moseley narrates the following very re^
markable and pertinent case. «

*' Captain Richard Boyle, of the third regiment of guards, was attacked in
London, on the 20th of January, 1785, from straining in pulling on his boots,
with a pulmonary haemorrhage, and almost suffocated by the violence of the
blood forcing itself through his mouth and nostrils. It was preceded by a
momentary tickling in his throat, that excited a fit of coughing; in which
an artery burst in the right lobe of his lungs. He was in the 23d year of his
age, and of a plethoric habit; but free from defect in make, that might indi-
cate such an event.

" He had many repetitions of the haemorrhage, after recovering from the
first, in the course of the same year; and was advised to go to the south of
France, to avoid the following winter in England. It was there that I saw

430 PRACTICE OF PHYSIC.

742. These are, in general, the phenomena of hae-
morrhage; and if, in some cases, all ol them be not ex-
quisitely marked, or if perhaps some of them do not at
all appear, it imports only, that, in different cases, the
system is more or less generally affected ; and that, in
some cases, there are purely topical haemorrhagies, as
there are purely topical inflammations.

Sect. II. — Of the Proximate Cause of Hcemorrhagy.

743. The pathology of haemorrhagy seems to be suf-
ficiently obvious. Some inequality in the distribution
of the blood occasions a congestion in particular parts
of the sanguiferous system; that is, a greater quantity of
blood is poured into certain vessels than their natural
capacity is suited to receive. These vessels become

him; and found the hemorrhage periodical; and so faithfully obeyed the in-
fluence of the moon, that a statement of the returns of such as came within
knowledge, will show one of the most decisive examples of lunar influence
in medical history.

" 1786, February 14th, he was attacked at Hieres near Toulon — Full moon
on the 13th. In this haemorrhage, he was for some time thought, by his at-
tendants, to be dead.

" February 20th, at Mx, in Provence. New moon on the 28th. Here,
also, he bled nearly to death.
" April 15th, at ditto. Full moon on the 13th.
" April 29th, at Tain, upon the Rhone. New moon on the 28th
" May 14th, at Chalons in Burgundy Full moon on the 13th.
" June 11th, at Dijon. It was then full moon.
" July 11th, at Paris. It was then full moon.

" August 9th, at Yarmouth, in the Isle of Wight. It was then full moon.
" The three last haemorrhages came on at the instant the moon appearec'
above the horizon."

On many other occasions, in the case of captain Boyle, did the haemor
rhagy from the lungs appear, at the time of the full or change of the moon,
with as much punctuality as in those we have recited.

Readers who may wish further to amuse themselves with many curious,
and not uninteresting facts and speculations, touching the influence of the
moon, not only in haemorrhagies, but on various other diseases, will be grati-
fietl by looking into the writings of Moseley, Mead, Ramazzini, Diemer-
broeck Ballonius, Van Helmont, Sennertus, Lord Bacon, Ambrose Pi
and many other authors of prior date.

PRACTICE OF PHYSIC, 431

thereby preternaturally distended; and this distention,
proving a stimulus to them, excites their action to a
greater degree than usual, which, pushing the blood
with unusual force into the extremities of these vessels,
opens them by anastomosis, or rupture; and, if these
extremities be loosely situated on external surfaces, or
on the internal surfaces of certain cavities that open out-
wardly, a quantity of blood flows out of the body.*

744. This reasoning will, in some measure, explain
the v production of haemorrhagy. But it appears to me,
that, in most cases there are some other circumstances
that concur to produce it; for it is probable, that, in con-
sequence of congestion, a sense of resistance arises, and
excites the action of the vis medicatrix naturse, the ex-
ertions of which are usually made by the formations of
a cold stage of pyrexia, inducing a more vigorous action
of the vessels; and the concurrence of this exertion
more effectually opens the extremities, and occasions
the flowing out of the blood.

745. What has been delivered in the two preceding
paragraphs, seems to explain the whole phenomena of
haemorrhagy, except the circumstance of its frequent re-
currence, which I apprehend may be explained in the
following manner. The congestion and consequent irri-

* This inequality is oftentimes produced, by that irregularity in the dis
tribution of the blood, which is requisite for the promotion of the growth
of the parts. When the bones of the face, for example, are acquiring their
ultimate expansion, they receive, for their nourishment, a larger portion of
blood, than they did at any former period, or than they do for their mere
subsistence, after they have attained to their full size The same thing is
true in relation to the lungs. Nor is it probable that the vessels of a part at-
tain their entire strength as soon as their growth is completed. The younger
they are, the more easily may they be lacerated. They acquire their size
first, and their strength and power of resistance, afterwards. These facts
may account, perhaps, in part, for the frequency of epistaxis and hemopty-
sis, about the age of puberty, when the bones of the face and the thorax,
with its contents, are acquiring their full size, with a progress more thai
usually rapid.

432 PRACTICE OF PHYSIC.

tation being taken off by the flowing of the blood; this
therefore, soon after, spontaneously ceases; but, at the
same time, the internal causes which had before pro-
duced the unequal distribution of the blood, commonly
remain, and must now operate the more readily, as the
over-stretched and relaxed vessels of the part will more
easily admit of a congestion of blood in them, and, con-
sequently, produce the same series of phenomena as
before.

746. This may sufficiently explain the ordinary return
of haemorrhagy; but there is still another circumstance,
which, as commonly concurring, is to be taken notice
of; and that is, the general plethoric state of the system,
which renders every cause of unequal distribution of
more considerable effect. Though haemorrhagy may
often depend upon the state of the vessels of a particu-
lar part being favourable to a congestion's being formed
in them; yet, in order to that state's producing its effect,
it is necessary that the whole system should be at least
in its natural plethoric condition; and, if this should be
in any degree increased beyond what is natural, it will
still more certainly determine the effects of topical con-
formation to take place. The return of haemorrhagy,
therefore, will be more certainly occasioned, if the sys-
tem becomes preternaturally plethoric; but haemorrhagy
has always a tendency to increase the plethoric slate
of the system, and, consequently, to occasion its own
return.

747. To show that hasmorrhagy does contribute to
produce or increase the plethoric state of the system, it
is only necessary to observe, that the quantity of serous
fluids being given, the state of the excretions depends
upon a certain balance between the force of the larger
arteries propelling the blood, and the resistance of the
excretories: but the force of the arteries depends upon

PRACTICE OF PHYSIC. 433

their fulness and distention, chiefly given to them by the
quantity of red globules and gluten, which are for the
greatest part confined to the red arteries; and therefore,
the spoliation made by an hfemorrhagy, being chiefly of
red globules and gluten, the effusion of blood must leave
the red arteries more empty and weak. In consequence
of the weaker action of the red arteries, the excretions
are in proportion diminished; and, therefore, the ingesta
continuing the same, more fluids will be accumulated
in the larger vessels. It is by this means that the loss
of blood by haemorrhagies, whether artificial or sponta-
neous, if within certain bounds, is commonly so soon:
recovered: but as the diminution of the excretions, from
a less quantity of fluid being impelled into the excreto-
ries, gives occasion to these vessels to fall into a con-
tracted state-, so, if this shall continue long, these ves-
sels will become more rigid, and will not yield to the
same impelling force as before. Although the arteries,
therefore, by new blood collected in them, shall have re-
covered their former fulness, tension, and force; yet this
force will not be in balance with the resistance of the
more rigid excretories, so as to restore the former state
of excretion; and, consequently, a further accumulation
will take -place in the arteries, and an increase of their
plethoric state be thereby induced. In this manner, we
perceive more clearly, that hajmorrhagy, as producing a
more plethoric state of the system, has a tendency to oc-
casion its own recurrence with greater violence; and, as
the renewal and further accumulation of blood require
a determinate time, so, in the several repetitions of ha3-
morrhagy, that time will be nearly the same; and there-
fore the returns of haemorrhagy will be commonly at
stated periods, as has been observed frequently to
happen.

748. I have thus explained the nature of hasmor-

vol. i 3 T

434 PRACTICE OF PHYSIC.

rhagy in general, as depending upon some inequality in
the distribution of the blood, occasioning a congestion
of it in particular parts of the sanguiferous system. It
is indeed probable, that, in most persons, the several
parts of the sanguiferous system are in balance with
one another; and that the density, and consequently the
resistance, in the several vessels, is in proportion to the
quantity of blood which each should receive; from
whence it frequently happens, that no inequality in the
distribution of blood takes place in the course of a long
life. If, however, we consider that the sanguiferous
system is constantly in a plethoric state, that is, that the
vessels are constantly distended beyond that size which
they would be of, if free from any distending force, we
shall be satisfied that this state may be readily changed.
For as, on the one hand, the vessels are elastic, so as
to be under a constant tendency to contract upon the
withdrawing of any part of the distending force; and,
on the other hand, are not so rigid, but that, by an in-
crease of the impetus of the blood in them, they may
be more than ordinarily distended; so we can easily un-
derstand how, in most persons, causes of an increased
contraction or distention may arise in one part or other
of the system, or that an unequal distribution may take
place; and how, in an exquisitely distended or plethoric
system, a small inequality in the distribution of the
blood may form those congestions which give occasion
to hasmorrhagy.

749. In this manner I endeavour to explain how hse-
morrhagy may be occasioned at any period of life, or in
any part of the body: but haemorrhagies happen in cer-
tain parts more frequently than in others, and at certain
periods of life more readily than at others; and there-
fore, in delivering the general doctrine of haemorrhagy.
it may be required that I should explain those circum

PRACTICE OF PHYSIC. 435

stances which produce the specialities mentioned; and
I shall now attempt it.

750. The human body, from being of a small bulk
at its first formation, grows afterwards to a considera-
ble size. This increase of bulk consists, in a great
measure, in the increase of the quantity of fluids, and
a proportional enlargement of the containing vessels.
But, at the same time, the quantity of solid matter is
also gradually inereased; and, in whatever manner we
may suppose this to be done, it is probable that the pro-
gress, in the whole growth of animal bodies, depends
upon the extension of the arterial system; and such is
the constitution of the sanguiferous system, that the
motion of the blood in the arteries has a constant ten-
dency to extend them in every dimension.**

751. As the state of the animal solid is, at the first
formation of the body, very lax and yielding; so the ex-
tension of the system proceeds, at first, very fast: but,
as the extension gives occasion to the apposition of
more matter to the solid parts, these are, in proportion
to their extension, constantly acquiring a greater den-
sity, and therefore giving more resistance to their fur-
ther extension and growth. Accordingly, we observe,
that as the growth of the body advances, its increase,
in any given time, becomes proportionally less and less,
till at length it ceases altogether.

752. This is the general idea of the growth of the

* Animal growth does not consist in mere extension. It is impossible, by
that process, ever to form large arteries out of small ones. It consists in
absorption and apposition. The absorbents remove entirely the smaller ar-
teries, while the vessels destined for the promotion of growth, lay down
larger and stronger ones in their places. On no other principles can the
growth of animal parts be explained Nor is it true, that the growth of the
body is always rapid, in proportion as the vessels are lax and tender. We
sometimes observe youth to grow more rapidly from sixteen to nineteen, or
even from seventeen to twenty-one, than at any former period. Our author's
doctrine is too coarse and mechanical to be true

436 PRACTICE OF PHYSIC.

human body, till it attain the utmost bulk which it is
capable of acquiring: but it is "to be remarked, that this
growth does not proceed equally in every part of the
body, it being requisite for the economy of the system,
that certain parts should be first evolved, and should
also acquire their full bulk sooner than others. This
appears particularly with respect to the head, the parts
of which appear to be first evolved, and soonest to ac-
quire their full size.

753. To favour this unequal growth, it is presumed,
that the dimensions or the laxity of the vessels of the
head, or that the direction of the force of the blood, are
adapted to the purpose; and from what has been said
in 751, it will also certainly follow, that as the vessels
of the head grow fastest, and soonest acquire their full
size, so they will soonest also acquire that density which
will prevent their further extension. While, however,
the force of the heart, and the quantity of the fluids,
with respect to the whole system, remain the same, the
distending and extending powers will be directed to
such parts as have not yet acquired the same density
and dimensions as those first evolved; and thus the
distending and extending powers will proceed to ope-
rate till every part of the system, in respect of density
and resistance, shall have been brought to be in balance
with every other, and till the whole be in balance
with the force of the heart, so that there can be no
further growth in any particular part, unless some pre-
ternatural circumstance shall happen to arise.

754. In this process of the growth of the body, as it
seems in general to depend upon a certain balance be-
tween the force of the heart or distending power, and
the resistance of the solids; so it will appear, that, while
the solids remain very lax and yielding, some occasional
increase of the distending power may arise without

PRACTICE OF PHYSIC. 437

producing any very perceptible disorder in the system.
But, it will also appear, that, in proportion as the dis-
tending power and resistance of the solids come to be
more nearly in exact balance with one another, so any
increase of the distending power will more readily pro-
duce a rupture of vessels, which do not easily yield to
extension.

755. From all this, it must follow, that the effects of
an unusually plethoric state of the system will be dif-
ferent, according as this shall occur at different periods
of the growth of the body. Accordingly it is evident,
that if the plethoric state arises while the head is yet
growing, and while the determination of the blood is
still more to the head than to the other parts, the in-
creased quantity of the blood will be especially deter-
mined to the head; and as there also, at the same time,
the balance between the distending and extending
powers is most nearly adjusted, so the determination
of the blood will most readily produce in that part a
rupture of the vessels, or an hasmorrhagy. Hence it
is, that hasmorrhagies of the nose so frequently happen
to young persons; and in these more readily, as they
approach nearer to their acme, or full growth; or, it
may be said, perhaps more properly, as they approach
nearer to the age of puberty, when, perhaps, in both
sexes, but especially in the female, a new determina-
tion arises in the system.

756. The determination of a greater quantity of blood
to the vessels of the head, might be supposed to occa-
sion a rupture of vessels in other parts of the head, as
well as in the nose: but such a rupture does not com-
monly happen; because in the nose there is, for the pur-
pose of sense, a considerable net-work of blood-vessels
expanded on the internal surface of the nostrils, and
covered only with thin and weak teguments. From this

438 PRACTICE OF PHYSIC.

circumstance it is, that upon any increased impetus of
the blood in the vessels of the head, those of the nose
are most easily broken; and the effusion from the nose
taking place, it not only relieves the other extremities
of the external carotid, to which the arteries of the nose
chiefly belong, but relieves also, in a great measure, the
system of the internal carotid. For, from the internal
carotid, certain branches are sent to the nose, are spread
out in its internal surface, and probably inosculated
with the extremities of the external carotid: so that,
whichsoever of the extremities are broken, the vis
derivationis of Haller will take place; the effusion will
relieve the whole sanguiferous system of the head, and
the same effusion will also commonly prevent an ha>
morrhagy happening at the same time in any other part
of the body.

757. From these principles, it will appear why has-
morrhagies of the nose, so frequent before the period
of puberty, or of the acme, seldom happen after these
periods: and I must observe further, that although they
should occur, they would not afford any objection to
my doctrine, as such haemorrhagies might be imputed
to a peculiar laxity of the vessels of the nose, and per-
haps to a habit acquired with respect to these vessels,
while the balance of the system might be otherwise duly
adjusted.

758. When the process of the growth of the body
goes on regularly, and the balance of the system is pro-
perly adjusted to the gradual growth of the whole, as
well as to the successive growth of the several parts,
even a plethoric state does not produce any hsemorrha-
gy, or at least any after that of the nose: but if, while
the plethoric state continues, any inequality shall also
subsist in any of the parts of the system, congestions, hae-
morrhagic or inflammatory, may be still readily formed.

PRACTICE OF PHYSIC. 439

759. In general, it may be observed, that, when the
several parts of the system of the aorta have attained
their full growth, and are duly balanced with one
another, if then any considerable degree of plethora re-
main or arise, the nicety of the balance will be between
the systems of the aorta and pulmonary artery, or be-
tween the vessels of the lungs and those of all the rest
of the body. And although the lesser capacity of the
vessels of the lungs is commonly compensated by the
greater velocity of the blood in them; yet, if this velo-
city be not always adjusted to the necessary compen-
sation, it is probable that a plethoric state of the whole
body will always be especially felt in the lungs; and,
therefore, that an haemorrhagy, as the effect of a gene-
ral plethora, may be frequently occasioned in the lungs,
even though there be no fault in their conformation.*

760. In some cases, perhaps, an haemorrhagy from
the lungs, or an haemoptysis, does arise from the gene-
ral plethoric state of the body; but an haemoptysis more
frequently does, and may be expected to happen, from
a faulty proportion between the capacity of the lungs
and that of the rest of the body.

761. When such a disproportion takes place, it will
be evident, that an haemoptysis will especially happen
about the time that the body is approaching to its
acme; that is, when the system of the aorta has arrived
at its utmost extension and resistance, and when, there-
fore, the plethoric state of the whole must especially
affect the lungs.

762. Accordingly, it has been constantly observed,
that the haemoptysis especially occurs about the time of
the body's arriving at its acme; but I must remark also,

* We recollect, at present, no facts or experiments, tending to show, that
the blood moves through the pulmonary system with greater velocity, than
in the other parts of the bodv.

440 PRACTICE OF PHYSIC.

that the haemorrhagy may occur sooner or later, ac-
cording as the balance between the vessels of the lungs
and those of the system of the aorta, happens to be
more or less exactly adjusted to one another; and it
may, therefore, often occur much later than the period
mentioned, when that balance, though not quite even,
is, however, not so ill adjusted, but that some other con-
curring causes are necessary to give it effect.

763. It was anciently remarked by Hippocrates, and
has been confirmed by modern observation, that the
haemoptysis generally occurs in persons between the
age of fifteen and that of five-and-thirty; that it may
happen at any time between these two periods; but that
it seldom happens before the former, or after the latter;
and it may be proper here to inquire into the reason of
these two limitations.

764. With respect to the first, the reason of it has
been already explained in 761. and 762.

With respect to the second limitation, I expect that
the reason of it will be understood from the following
considerations.

It has been already observed, that the extension and
growth of the body require the plethoric state of the ar-
terial system; and nature has provided for this, partly
by the constitution of the blood being such that a great
proportion of it is unfit to pass into the exhalants and
excretories; partly by giving a certain density and re-
sistance to the several exhalants and excretories through
which the fluids might pass out of the red arteries; and
partly, but especially, by a resistance in the veins to
the free passage of the blood into them from the ar-
teries.

765. With respect to this last and chief circum-
stance, it appears from the experiments of Sir Clifton
Wintringham, in his Experimental Inquiry, that the

PRACTICE OF PHYSIC. 441

proportional density of the coats of the veins to that of
the coats of the arteries, is greater in young than in old
animals: from which it may be presumed, that the re-
sistance to the passage of the blood from the arteries
into the veins, is greater in young animals than in old ;
and, while this resistance continues, the plethoric state
of the arteries must be constantly continued and sup-
ported. As, however, the density of the coats of the ves-
sels, consisting chiefly of a cellular texture, is increased
by pressure; so, in proportion as the coats of the arte-
ries are more exposed to pressure by distention than
those of the veins, the former, in the progress of the*
growth of the body, must increase much more in den-
sity than the latter; and, therefore, the coats of the ar-
teries, in respect of density and resistance, must come,
in time, not only to be in balance with those of the veins,
but to prevail over them ; a fact which is sufficiently
proved by the experiments of the above-mentioned in-
genious author.

By these means, the proportional quantities of b'ood
in the arteries and veins must change in the course of
life. In younger animals the quantity of blood in the
arteries must be proportionally greater than in old
ones; but by the increasing density of the arteries,
the quantity of blood in them must be continually di-
minishing, and that in the veins be proportionally in-
creasing, so as at length to be in a proportionally greater
quantity than that in the arteries. When this change
happens in the proportional quantities of the blood in
the arteries and veins, it must be evident that the ple-
thoric state of the arteries will be in a great measure
taken off; and therefore that the arterial ha?morrhagy
is no longer likely to happen; but that if a general ple-
thoric state afterwards take place in the system it must
especially appear in the veins.

vol. i. 3 k

PRACTICE Oi PHYSH

766. The change I have mentioned to happen in the
state of the arterial and venous systems, is properly sup
posed to take place in the human body about the age of
thirty-five, when it is manifest that the vigour of tin-
body, which depends so much upon the fulness and
tension of the arterial system, no longer increases; and
therefore it is, that the same age is the period after which
the arterial haemorrhagy, haemoptysis, hardly ever ap-
pears. It is true, there are instances of the haemopty-
sis happening at a later period; but it is for the reasons
given (757.) which show that an hcemorrhagy may hap-
pen at any period of life, from accidental causes form-
ing congestions, independent of the state of the balance
of the system at that particular period.

767. 1 have said (765.) that if, after the age of thirty-
five, a general and preternatural plethoric state occur, it
must especially appear in the venous system; and I must
now observe, that this venous plethora may also give
occasion to haemorrhagy.

768. If a plethoric state of the venous system take
place, it is to be presumed, that it will especially and in
the first place affect the system of the vena portarum,
in which the motion of the venous blood is more slow
than elsewhere; in which the motion of the blood is
little assisted by external compression; and in which,
from the want of valves in the veins that form the vena
portarum, the motion of the blood is little assisted by
the compression that is applied; while, from the same
want of vahes in those veins, the blood is more ready
to regurgitate in them. Whether any regurgitation of
the blood can produce an action in the veins, and which,
inverted or directed towards their extremities, can force
these, and occasion haemorrhagy, may perhaps be dis-
puted: but it appears to me that an haemorrhagy, pro-
duced by a plethoric state of the veins, may be ex-

PRACTICE OF PHYSIC. 443

plained in another and more probable manner. If the
blood be accumulated in the veins, from an interrup-
tion of its proper course, that accumulation must resist
the free passage of the blood from the arteries into the
veins. This again must produce some congestion in
the extremities of the red arteries, and therefore some
increased action in them, which must be determined
with more than usual force, both upon the extremities
of the arteries, and upon the exhalants proceeding from
them; and this force may occasion an effusion of blood,
either by anastomosis or rupture.

769. In this manner I apprehend the haemorrhoidal
flux is to be explained, so far as it depends upon the
state of the whole system. It appears most commonly
to proceed from the extremities of haemorrhoidal ves-
sels, which, being the most dependent and distant
branches of those veins that form the vena portarum,
are therefore the most readily affected by every accu-
mulation of blood in that system of veins, and conse-
quently by any general plethora in the venous system.

770. It is here to be observed, that I have spoken of
this haemorrhagy as proceeding from the haemorrhoidal
vessels only, as indeed it most commonly does, but it
will be readily understood, that the same accumulation
and resistance to the venous blood may, from various
causes, affect many of the extremities of the vena porta-
rum, which lie very superficially upon the internal sur-
face of the alimentary canal, and give occasion to what
has been called the Morbus Niger or Melcena.

771. Another part in which an unusually plethoric
state of the veins may have particular effects, and oc-
casion haemorrhagy, is the head. In this, the venous
system is of a peculiar conformation, and such as seems
intended by nature to give there a slower motion to the
venous blood. If, therefore, the plethoric state of the

444 PRACTICE OF PHYSK

venous system in general, which seems to increase as
life advances, should at length increase to a great de-
gree, it may very readily affect the venous vessels of the
head, and produce there such a resistance to the arterial
blood, as to determine this to be poured out from the
nose, or into the cavity of the cranium. The special
effect of the latter effusion will be, to produce the dis-
ease termed Apoplexy ; and which, therefore, is pro-
perly named by Dr. Hoffman, Hcemorrhagia Cerebri:
and the explanation of its cause, which I have now
given, explains well why it happens especially to men
of large heads and short necks, and to men in the decline
of life, when the powers promoting the motion of the
blood are much weakened.*

772. I have tlius attempted to give the history of the
plethoric and hasmorrhagic states of the human body,
as they occur at the different periods of life; and hope
I have thereby explained, not only the nature of hse-

* We do not believe that apoplexy is ever produced, in the manner
stated in this article. It is certainly, in most cases, if not always, a gastric
disease, the brain being only secondarily affected. Hence it is, that, in
those predisposed to it, it is so often excited by a meal inordinately full,
or consisting of materials crude and indigestible, a debauch in drinking, or
any other cause that produces a morbid and strong impression on the
stomach. Those cases of apoplexy which arise from the passions of the
mind, are the only ones perhaps that have not a gastric origin.

Notwithstanding the acuteness of perception, and ingenuity of reason-
ing, which our author has displayed, in his inquiry respecting the proximate-
cause of haemorrhagy, the entire section wherein it is contained is little
else but an elaborate and intricate tissue of error. In all the essential
qualities of inconclusiveness, it is ©n a level with his theories of inflamma-
tion and fever.

We regret our inability to offer any thing new or satisfactory on this sub •
ject. A correct theory of hxmorrhagy constitutes a desideratum in the
science of pathology. That desideratum, however, we shall not, at present,
attempt to supply.

Nor will our practical consideration of the disease be found to suffer ma-
terially from the want of it. For, here, as in other instances, correct prac-
tice is not the result of theory, but experience. However satisfactory-
'.herefore, a rational theory might be, to the philosopher, it is not, in the.
strict interpretation of the term, essential to the practitioner.

PRACTICE OF PHYSIC. US

morrhagy in general, but also of the particular hsemor-
rhagies which commonly appear, and as they occur
successively at the different periods of life.

Sect. HI. — Of the Remote Causes of Hceinorrhagy.

i

773. In the explanation hitherto given, I have espe-
cially considered the predisposition to haemorrhagy:
but it is proper also, and even necessary, to take notice
of the occasional causes, which not only concur with
the predisponent, in exciting haemorrhagy, but may
also sometimes be the sole cause of it.

774. These occasional causes are,

1. External heat, which, by rarefying the blood, pro-
duces or increases the plethoric state of the body; and
the same heat, as giving a stimulus to the whole system,
must urge any particular determinations before esta-
blished, still further, or may urge to excess any inequa-
lity, otherwise innocent; so that, in either way, exter-
nal heat may immediately excite haemorrhagies, to
which there was a predisposition; or may form conges-
tions where there were none before, and thereby occa-
sion haemorrhagy.*

* External heat does not rarefy the blood. It only appears to rarefy it, in
consequence of eliciting it towards the surface of the body, and the extre-
mities, by means of its stimulant impression ; thus giving-, to these parts, a
visible turgescence which they did not before possess.

In the production of hsemorrhagy, therefore, external heat operates in a
two-fold way. It increases the force and rapidity of the general circulation,
and produces a local congestion, in superficial vessels, where it did not pre-
viously exist. From the former effect may arise haemorrhagies, either ex-
ternal or internal ; from the latter, external haemorrhagies only.

We, not long since, saw a female discharge, from her mouth, we believe
it ci»me from the fauces, a considerable portion of blood, in consequence of
a violent paroxysm of anger.

Parts of the body, whence blood is like to flow, or is actually flowing,
should be kept, as far as possible, from a depending positron. Hence, in
epistaxis, the body should be erect j and, in cases of uterine haemorrhagy, fe-
males should not only lie in bed, but have their hips somewhat elevated

<4b PRACTICE OF PHYSIC.

2. A considerable and sudden diminution of the
weight of the atmosphere, which seems to occasion the
same effects as heat, by producing also an expansion ot
the blood.

3. Whatever increases the force of the circulation,
and thereby the velocity of the blood, may operate in
the same manner as heat, in urging not only previous
determinations with violence, but also in urging to ex-
cess inequalities, otherwise innocent. All violent exer-
cise, therefore, and especially all violent efforts, which,
not only by a larger and longer inspiration, but also by
the simultaneous action of many muscles interrupting
the free motion of the blood, impel it with unusual force
into the extreme vessels more generally, and, according'
to the different postures of the body, and mode of the
effort, into certain vessels more particularly.

Among the causes increasing the force of the circu-
lation, anger and other violent active passions are to be
reckoned.

4. The violent exercise of particular parts of the body.
If these are already affected with congestions, or liable
to them, such exercise may be considered as a stimulus
applied to the vessels of that particular part. Thus, any
violent exercise of respiration may excite hasmoptysis,
or occasion its return.

5. The postures of the body increasing determina-
tions, or ligatures occasioning accumulations of the
blood in particular parts of the body.

6. A determination into certain vessels rendered ha-
bitual by the frequent repetition of haemorrhagy from
them.

7. Cold, externally applied, as changing the distribu-

This latter position is also useful in the treatment of profuse barmorrhoidal
discharges.

PRACTICE OF PHYSIC. 447

tion of the blood, and determining it in greater quantity
into the internal parts.

Sect. IV. — Of the Cure of Hccmorrhagy.

775. Having thus considered the proximate and re-
mote causes of haemorrhagy in general, our next business
is, to treat of the cure of the disease in the same manner.

In entering upon this subject, the first question which
presents itself, is, Whether the cure of haemorrhagies
ought to be attempted by art, or if they should be left
to the conduct of nature?

776. The latter opinion was the favourite doctrine of
the celebrated Dr. Stahl, and his followers. They
maintained that the human body is much disposed to a
plethoric state; and, consequently, to many disorders
which nature endeavours to obviate and relieve by ex-
citing haemorrhagy: that this, therefore, is often neces-
sary to the balance and health of the system: that it is
accordingly to be generally encouraged, sometimes so-
licited, and is not to be suppressed, unless when it goes
to great excess, or happens in parts in which it may be
dangerous.

777. Much of this doctrine may be admitted. The
human body, upon many occasions, becomes preter-
naturally plethoric; and the dangerous consequences
which might from thence be apprehended, seem to be
obviated by an haemorrhagy taking place: and, further,
the necessity of haemorrhagy often appears from hence,
that the suppression of it seems to occasion many dis-
orders.

All this seems to be just; but, in the conclusion
drawn from it, there is a fallacy.

778. It appears to me certain, that haemorrhagy,
either upon its first attack, or upon its first recurrence,
is never necessary to the health of the body, excepting

448 PRACTICE OF PHYSIC.

upon the supposition, that the plethoric state which
seems to require the evacuation, cannot be otherwise
prevented or removed; and as I imagine it possible by
other means to prevent or remove a plethoric state, so
I do not think that haemorrhagy is, in all cases, neces-
sary. In general, I am of opinion that haemorrhagy is
to be avoided.

1. Because it does not always happen in parts where
it is safe.

2. Because often, while it does relieve a plethoric
state, it may, at the same time, induce a very dangerous
disease.

3. Because it may often go to excess, and either en-
danger life, or induce a dangerous infirmity.

And, lastly, Because it has a tendency to increase the
plethoric state it was meant to relieve; to occasion its
own recurrence, (120.) and thereby to induce a habit,
which, if left to the precarious and unequal operation
of nature, may, from the frequent errors of this, be at-
tended with much danger.

779. It is further to be considered, that hsemorrha-
gies do not always arise from the necessities of the sys-
tem, but often proceed from incidental causes. It ap-
pears to me that all haemorrhagies of the latter kind
may be immediately suppressed, and the repetition of
them, as it induces a plethora, and a habit not other-
wise necessary, may be prevented with great advantage.

780. Upon the whole of this subject, I conclude, that
every preternatural haemorrhagy, or, in other words,
every one except that of the menses in females, is to be
avoided, and especially the returns of it prevented; and
I therefore now proceed to mention, how haemorrhagy,
and its recurrences, may, and should be prevented.

781. From the principles delivered above, it will im-
mediately appear, that the prevention, either of the first

PRACTICE OF PHYSIC. 449

attacks, or of the returns of haemorrhagy, will chiefly,
and in the first place, depend upon the preventing or re-
moving any considerable degree of a plethoric state
which may happen to prevail in the body. It is true,
that, where the haemorrhagy depends upon the particu-
lar conformation of certain parts, rather than upon the
general plethoric state of the whole, the measures for
removing or preventing the latter may not always be
sufficient for preventing haemorrhagy : but at the same
time it must be evident, that determinations, in conse-
quence of the conformation of particular parts, will al-
ways be urged more or less, in proportion to the greater
or lesser degree of the plethoric state of the whole sys-
tem; and therefore, that even in the cases depending
upon particular conformation, the preventing or remov- (
ing an unusual plethoric state will always be a chief
means of preventing haemorrhagy. It is further to be
attended to, that there may be several inequalities in the
balance of the system, which may have little or no
effect unless when the system becomes preternaturally
plethoric; and, therefore, that in all cases the prevent-
ing or removing of the plethoric state of the system will
be a chief means of preventing the first attacks, or the
returns of haemorrhagy. It now therefore remains to
explain, how the plethoric state of the system is to be
prevented or removed.

782. The fluids of the human body are in continual
waste by the excretions, but are commonly replaced by
the aliments taken in; and if the quantity of aliments
in any measure exceed that of the excretions, an in-
crease of the quantity of the fluids of the body, or, in
other words a plethoric state, must necessarily arise.
This, to a certain degree, is requisite for the growth of
the body, but even then, if the proportion of the ali-
ments to the excretions, be greater than is suited to the

vol. i. 3 L

450 PRACTICE OF PHYSIC.

growth of the body, and more certainly still, if, alter the
growth is completed, when an equality between the in-
gesta and the excreta should be established, the dispro-
portion still continue, a preternaturally plethoric state
must arise. In both cases, it is evident that the plethora
must be prevented or corrected by adjusting the ingesta
and excreta to each other; which ge